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Death Certificate Filing Requirements ~ , Death Certificate Filing Requirements · The Death Certificate must be filed within 72 hours of death or finding of a body · Certificate is to be filed by a NYS licensed Funeral Director · If the 'body has not been turned over to the Funeral Director it is the responsibility of the person in charge of the body to file the Death Certificate (Coroner or Facility) · Certificate is to be filed in the Registration District where death occurred , ..- 2003 Death Certificate Revisions · All "XXXXXX's" have been removed from all date fields. Continue entering all dates as MM/DDNYYY. · Place of Death (Item 4A): a checkbox has been added for "Hospice Facility." · Decedent of Hispanic Origin? (Item 9): checkboxes have been added indicating country of origin. Check as many boxes as appropriate. · Decedent's Race (Item 10): Choose as many checkboxes as appropriate. Specify if necessary. ~ iJ 2003 Death Certificate Item 4A: Place of Death 4A. PLACE OF DEATH: HOSPITAL HOSPITAL HOSPITAL (Check one) DOA ER OUTPATIENT INPATIENT D D D D NURSING HOME D PRIVATE RESIDENCE D HOSPICE FACILITY D · Hospice Facility item added OTHER (Specify) : D 2003 Death Certificate Item 9: Hispanic Origin 9. DECEDENT OF HISPANIC ORIGIN? Check the boxes that best describe whether the decedent is Spanish/Hispanic/Latino. A D No, not Spanish/Hispanic/Latino B D Yes, Mexican, Mexican American, Chicano cD Yes, Puerto Rican D D Yes, Cuban E D Yes, Other Spanish/Hispanic/Latino (specify) 2003 Death Certificate Item 10: Decedent's Race 10. DECEDENT'S RACE: Check one or more races to indicate what the decedent considered himself or herself to be. A D White/Caucasian B D Black or African American C D Asian Indian D D Chi~ese E D Filipino F D Japanese G D Korean H D Vietnamese J D Native Hawaiian K D Guamanian or Chamorro M D Samoan N D American Indian or Alaska Native (specify) , P D Other Asian (specify) R D Other Pacific Islander (specify) S D Other (specify) 2003 Death-Cert Revisions Continued · Education (Item 11): Check the box that best describes the highest degree or level of school completed at the time of death. · Marital Status (Item 13) Boxes realigned; Separated means legally separated. · Disposition (Item 20A) Check appropriate box - entombment is a burial. 2003 Death Certificate Item 11: Decedent's Education 11. DECEDENT'S EDUCATION: Check the box that best describes the highest degree or level of school completed at the time of death. 1 D ~ 8th grade 2 D 9th-12th grade; no diploma 3 D High school graduate or GED 4 D Some college credit, but no degree 5 D Associate1s degree 6 D Bachelor's degree 7 D Masters degre~ 8 D Doctorate/Professional degree 2003 Death Certificate Item 20A: Disposition 20A. 1 D BURIAL 2 D CREMATION 3 D REMOVAL 4 D HOLD I I MONTH DAY YEAR . 5 D ANATOMICAL GIFT -. I I · Check boxes added. · For "Entombment" check "BURIAL" 2003 Death Certificate Certifier Revisions in Landscape · Items 25 thru 33 to be completed by Certifying Physician, Coroner/Coroner's Physician or Medical Examiner · Item 25A check appropriate box and complete. If the Attending Physician is not available a physician acting on his/her behalf is to certify the death certificate. The Attending Physician's info is to be entered in 25C. If Coroner's case Coroner completes 25A, if Coroner not a physician Coroners Physician completes 25B. If Attending Physician completes 25A and it is a Coroner's case a DOH 1999 must be filed to correct 25A. 2003 Death Certificate Items 25A. - 29B. cor" not a physician: Coronets Physician's Name: ~, 25C. If certifier. not attending physician: A11endi~g Pjrfsician's Name: 26A Attending physician attended deceased: FROM TiUe: Ucense No.: Signature: ~ TiUe: Ucense No.: Address: Year 268. Deceased last seen alive by attending physician: Time 2003 Death Certificate Revisions Cause of Death · New item: Did Tobacco use contribute to Death? Check appropriate box. · If Transportation Injury (Item 31F) Items have been added indicating the role of the decedent. · Was Decedent hospitalized in last 2 months? Do not include current hospitalization. · If Female Pregnant (Item 33A): Additional checkboxes to indicate if a female was pregnant within specified periods. 2003 Certificate of Death Tobacco Use Question Added to Cause of Death PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART I (A): DID TOBACCO USE CONTRIBUTE TO DEATH? o D NO 1 DYES 2 D PROBABLY 3 D UNKNOWN 2003 Death Certificate Item 31F: Transportation Injury 31 F. IF TRANSPORTATION INJURY, SPECIFY: 10 Driver/Operator 20 Passenger 3D Pedestrian 40 OTHER (specify) 2003 Death Certificate Item 33A: Pregnancy 33A. IF FEMALE: o D Not pregnant within last year 1 D Pregnant at time of death 3 D Not pregnant, but pregnant 43 days to 1 year before death 2 D Not pregnant, but pregnant within 42 days of death 4 D Unknown if pregnant wIThin past year Public Health Law 4140 · 1) The death of each person who has died in this state shall be registered immediately and not later than 72 hrs after the death or finding of the body in the appropriate registration district · 2) If the certificate of death is properly executed and complete the local registrar will issue a burial permit (DOH-1555) · 1) The information will be submitted on a form prescribed by the Commissioner · 2) The personal particulars shall be furnished py a competent person (Informant) · 3) The disposition section shall be completed by the funeral director or undertaker in charge · 4) The medical certificate shall be completed by a physician (Attending, Certifying, Coroner's or Medical Examiner) Public Health Law 4141 a Hospital Administrator Duty · When a death occurs in a hospital, except in coroners or Medical Examiner cases, the person in charge of the hospital shall promptly present the certificate to the physician in attendance or a certifying physician acting in his/her behalf to promptly certify to the facts of death and sign the certificate to meet the 72 hour requirement. Public Health Law 4142 duties of Funeral Director · A) Obtain the personal and statistical particulars to complete the certificate from the Informant · B) Present the certificate promptly to the attending physi~ian for medical completion · C) Complete the disposition section and sign · D) Prior to the disposition of remains file the death certificate and obtain a Burial Permit PHL 4143 registration w/o medical attendance · 1) Funeral Director notifies the county coroner or medical examiner of the death · 2) When notified the coroner or ME shall immediately investigate and certify the death · 3) Coroner or ME shall give name of disease causing death or if by external cause the means of death · 4) If death is in Erie County the Medical Director must do investigation PHL 4144 Burial and Removal Permits and remains transport · 1) The body may not be interred, cremated, removed or held more than 72 hours in this state without the issuance of a Burial Permit (DOH- 1555) to a NYS licensed funeral director · 2) Issue Permit only when DC is filed · 3) No registrar receives fee for issuing a permit · 4) If from outside the state the permit issued by the other state will be given same force and effect · 5) Registrar completes the permit · 6) Removal from trains, boats and airplanes · 7) NYC single county PHL 4145 Burial and Removal Permits remains disposition · 1) No person in charge of any disposition premises shall accept a body for disposition wlo a Burial Permit · 2) The Funeral Director will deliver to the person in charge of the place of disposition. If remains are shipped by a transportation company the permit must accompany the remains . 3)The person in charge of the premises completes the endorsement section and files with the registrar in this district within 7 days PHL 4145 continued · 4) If there is no person in charge of the premises where disposition takes place the Funeral Director signs and dates the permit and writes "No person in charge" across the face of the permit and files with local registrar within 3 days · 5) The person in charge of the premises shall keep a record of all dispositions this record shall at all times be open to official inspection Title 10 DOH Rules & Regs 35.4 Issue Certified Copies only · 1) Pursuant to a court order showing necessity · 2) Upon specific request from current spouse, children or parents of the decedent · 3) When a documented need to establish a . legal right or claim has been demonstrated · 4) When a documented medical need has been demonstrated 35.4 Rules & Regs Continued 35.4 Rules & Regs Continued · C) Commencing on Jan 1, 1988 all death certificate forms will contain a confidential cause of death section. This section is to be removed from all copies unless a demonstrated need is shown . Funeral Director Copies when filing a death certificate it is customary for the Funeral Director to request copies we ask the FDs to complete form DOH-294A when requesting copies Public Health Law 4160 Fetal Death Registration · l) Fetal death is defined as death prior to complete expulsion or extraction from the mother · 2) All fetal deaths must be filed within 72 hours after expulsion of such fetus · 3) A fetal death shall be considered a birth and death · 4) Local registrars will confidential destroy after 30 days from date of event · 5) Copies only available to the mother, from NYS Public Health Law 4162 Fetal Death Burial Permits · 1) A permit is required for the removal, transportation, burial or other disposition of remains resulting from fetal death with a gestation period of 20 weeks or longer . 2) The permit is to be issued by the local registrar where event took place if gestation period is 20 weeks or longer. If burial is requested by family for under a 20 week gestation no permit is required or will be issued. 2003 MedicallBurial Death Correction Report Name of Deceased Medical/Burial Death Correction Report Date of Death Place of Dealh 2OC.lOCATION, iCi.abwl..waQ". 21B. REGISTRATION NUMBER: 21C REClSffiATION NUMBER .24A., BURIAl OR REMOVAl PERMIT ISSUEO BY: 0, CeRnFlCA~a..'C~Q((wE: 0 I~..alnq~_" .al,,","iM~lJlblhall'li'''iIIllnin;jptJ,ai;.' ioIIlflilo:"~rJ""'~,IiNIh_iXQJ'AJd.:t.."'.dK'.nd~lDJlilI;~U.~".d. 11rll1hln-........~f1*ItII..... CInlIW'.llr . lptl)llQltla'lll en...... rJ_~~~....,.._.,...1'B:nSWJ n"'ClllIDl.dldllUWTeda lhIllI1'e. _ ....p.:.andllie!DlIwc:a,....ted - . r.: ~ ..No.: ~An _ 110, ,_ /:;:~, . .. ~, ffi- iL J: 58.11_.1lllIl4~ c.--t~l": 0:: W 25C...c........_.~JlI\'aINtl:CGoI....~1I"-r l.> 2....__..~ al'-Itd....lld:RQ1 I --... To be completed by registrar of vital statistics: The above informalkJn ha6 been added to the local record of death on file in this office. ,. .'. ';:,..~! ;{ ~ r'W r-'-- 10""""'''''' I DOl. 00H-1999" (1112002) vs.... 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 20B. PLACE OF BURIAL, CREMATION, REMOVAL OR OTHER DISPOSITION: 20C. LOCATION; (City or town and state) Z 20A. 1 o i= en o Q. (IJ C 21B. REGISTRATION NUMBER: 21A. NAME AND ADDRESS OF FUNERAL HOME: 22B. SIGNATURE OF FUNERAL DIRECTOR: 22C. REGISTRATION NUMBER: 22A. NAME OF FUNE 23A. ~ 25A CERTIFICATION _ CHECK ONE: fi attending pny.;ician or a ~iclan acting 011 behaff of the attending pI1)siclan and to the best of my knowledge, death ocamed allhe time. dale and place and due to the causes staled. o I am the medical examner, deputy medical " coroner, or corone<'s pI1)siclan and 011 the basis of ImesligalMlO and such examnatiOnS as I fell necessary, In my opinion, death ocamed at the time, date and place and due to the causes staled. Name: . License No.: Signature: Mon" OilY v.. ~ :I: ~ < W C LL. o W (IJ ::> < u 258_ If coroner, not a physician: Coroner'".s Physicisn'$ Name: v_ e:::: Address: W u: i= ~ w u Torre M APPROXJW\TE ItmR'lAl BElWEEN ONsET ANa DEATH DID TOBACCO USE CONTRIBUTE TO DEATH? 00 NO 1 DYES 2 0 PROBABLY 3 D UN<NOWN 31 E. INJURY AT WORK? NO YEs 00 0, 33B. DATE OF DELIVERY: MONTH DAY YEAR lDDrl_JOperalof 2 0 p~ 3D PedltUlan 40 OTHER /sp.my) ff pregnant w~hin past l"'l' Affirmation to be completed by Funeral Direct@(ltem 20A-24B) or Certifyi hysician (Item 25A-33B): I affiem undee penalties (oe peejucy that the in(onnati~iven.i.!ite facsimile of the certmeate of death (oe the deceased pecson identified above is true and correct information to be added to the Origiy rtificate of death and the local registrar's record. Signature Ti elationship to Deceased Date To be completed by registrar of vital statistics: M The above information has been added to the local record of death on file in this o1fe. Registrars SIgnalure District Number Date ... . VS64B