Medical/Burial Death Correction Report
STATE OF NEW YORK
DEPARTMENT OF HEALTH
VITAL RECORDS SECTION
DISTRICT #
REGISTER #
STATE FILE #
Name of Deceased
Medical/Burial Death Correction Report
Date of Death Place of Death
MONTH DAY YEAR
Z 2OA.1 0 BURIAL 20 CREMATION 3D REMOVAL
o 40HOLD SODONATION MONTH
j: 60 ANATOMICAL GIFT
(ij 21A. NAME AND ADDRESS OF FUNE;filM HOME:
2 I!!~
o 22A. NAME OF FUNERAL DIRECTOR"
is
20B. PLACE OF BURIAL, CREMATION, REMOVAL OR
OTHER DISPOSITION:
20C. LOCATION; (City or town and state)
21B. REGISTRATION NUMBER:
22B. SIGNATURE OF FUNERAL DIRECTOR:
22C. REGISTRATION NUMBER:
23A. SIGNATURE OF REGISTRAR:
24A. BURIAL OR REMOVAL PERMIT ISSUED BY:
~
25A. CERTIFICATION:
YEAR
Certifier's Name
Year
Signature
Year
25C If certifier is not attendmg physician. enter Attending Physician's name & title
Address
26A. Attending physICian
attended deceased
FROM
Time
M
27. MANNER OF DEATH
NATURAL CAUSE
01
CONFIDENTIAL
CONFIDENTIAL
APPOOlOfotA TE INTERVAL
BETWEEN ONSET AND DEATH
30. DEATH WAS CAUSED BY:
PART I. IMMEDIATE CAUSE:
(A)
DUE TO OR AS A CONSEQUENCE OF:
(B)
DUE TO OR AS A CONSEQUENCE OF:
(C)
PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING . .' ~I
DEATH BUT NOT RELATED TO CAUSE GIVEN IN PAR C\ I
131B, INJURY lOCALITY: (City or town a '~nty and state) I 31C. DESCRIBE HOW INJURY OCCU 'ED
I 0J I
M,. I
32 WAS DECEDENT 33A IF FEMALE
HOSPITALIZED
IN LAST 2 MONTHS?
DID TOBACCO USE CONTRIBUTE TO DEATH?
:J:
tic
w
c
u..
o
w
o
~
()
OONO 1 DYES
I 310 PLACE OF INJURY
I
I
20 PROBABLY 3D UNKNOWN
I 31E INJURY AT WORK?
NO YES
: Do 01
33B. DATE OF DELIVERY:
YEAR
NO YES
0001
ys 10 1 year before death
~' nt
20 Nol pregn.anl. but pre" "". I hln 42 days of death
Ii \\ ,I
40 Unknown If pregnant th\!lijasl year
i " I:
1\1
Affirmation to be completed by Funeral Director (Item 2~-24~r~ Certifying Physician (Item 25A-33B):
I affirm under penalties for perjury that the information given in the faCS\~i~ of the certificate of death for the deceased person identified
above is true and correct information to be added to the original certificat~ d ~j. 1..1 and the local registrar's record.
r. !\'" ~
. \:
Title or Relationship to oecetrd
~
Signature
Dale
To be completed by registrar of vital statistics:
The above information has been added to the local record of death on file in this office.
Registrar's Signature
District Number
Date
DOH-l999 (02/2003)