77 Ill. Adm. Code 500.APPENDIX G
G Death Records
TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER f: VITAL RECORDS
PART 500 ILLINOIS VITAL RECORDS CODE
SECTION 500.APPENDIX G DEATH RECORDS
Section 500.APPENDIX G
Death Records
Section 500.ILLUSTRATION B Necropsy
(NEC)1
NEC 1
CORONER
(Rev. 3/69)
Report
of Coroner's Physician to the
Coroner
of _______________________County, Illinois
have
examined
have
made a necropsy on the
I,
M.D.,
body
identified to me by the coroner of this county as being:
Name
__________________________________________ Date of Death
________________________________
Place of Death
(city, village, or twp.)
_________________________________________________________________
Place of Examination
(city, village, or twp.)
____________________________________________________________
In my opinion, the cause of
death was as follows:
[Enter only one cause per line for (a), (b), and
(c).]
APPROXIMATE INTERVAL
BETWEEN ONSET AND DEATH
CONDITIONS, IF ANY, WHICH
GAVE RISE TO IMMEDIATE CAUSE (a) STATING THE UNDERLYING CAUSE LAST.
IMMEDIATE CAUSE
(a)
DUE TO, OR AS A CONSEQUENCE
OF
(b)
DUE TO, OR AS A CONSEQUENCE
OF
(c)
OTHER
SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL
CONDITIONS GIVEN ABOVE.
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
My
conclusions are based on the following observations and findings.
Date:
Signed:
M.D.
Coroner's Physician
INSTRUCTIONS: 1.
Prepare this form in triplicate. Use typewriter for all entries except
signature.
2. Sign original and first copy in pen
and ink.
3. Mail original and first copy to the
coroner. Retain last copy.