Death Certificate Form

PURPOSE: This rule establishes the content of the death certificate for each death in this state to be filed with the Department of Health. (1) The death certificate shall include the following items: registration district number; registrar’s number; decedent’s name, sex, date of death, Social Security number, age (under 1 year—months and days—under 1 day—hours, minutes), date of birth, birthplace, was decedent ever in United States armed forces—yes, no or unknown; place of death—hospital (specify inpatient, emergency room (ER)/outpatient or dead on arrival (DOA)) or other (specify nursing home, residence or other); facility name; city, town or location of death; county of death; marital status; surviving spouse’s name; decedent’s usual occupation; kind of business or industry; residence—state, county, city town or location—zip code, street and number, inside city limits, years at present address; was decedent of Hispanic origin—no or yes—specify; race; decedent’s education; father’s name, mother’s name; informant’s name, mailing address; burial, cremation or other (specify); date of disposition; place of disposition; location; signature of funeral service licensee or person acting as such; name and address of facility; funeral establishment license number; immediate cause and underlying causes of death and approximate interval between onset and death; other significant conditions contributing to death; if deceased was female 10–49, was she pregnant in the last 90 days—yes, no or unknown; was autopsy performed—yes or no; were autopsy findings available prior to completion of cause of death—yes or no; manner of death; date of injury; time of injury; injury at work—yes, no or unknown; describe how injury occurred; check whether certifying physician or medical examiner/coroner; signature and title of certifier; date signed; time of death; name and address of certifier, Missouri license number; case referred to medical examiner/coroner—yes or no; name of attending physician if other than certifier; registrar’s signature; and date received by local registrar. AUTHORITY: section 193.145, RSMo 2000.* This rule was previously filed as 13 CSR 50-150.050 and 19 CSR 30-10.050. Original rule filed Nov. 4, 1977, effective Feb. 11, 1978. Rescinded and readopted: Filed Sept. 12, 1988, effective Jan. 1, 1989. Changed to 19 CSR 10-10.050 July 30, 1998. Amended: Filed Oct. 2, 2002, effective March 30, 2003. *Original authority: 193.145, RSMo 1984, amended 1989, 1997.