U.S. STANDARD CERTIFICATE OF DEATH
2. SEX

Maria Ofelia Garcia
4a. AGE-Last Birthday
(Years)

78

Months

Hours

Minutes

06/22/1934

7b. COUNTY

7d. STREET AND NUMBER

Medellin, Colombia
7c. CITY OR TOWN

7e. APT. NO.

8. EVER IN US ARMED FORCES?
Yes
No

048-90-XXXX

5. DATE OF BIRTH (Mo/Day/Yr) 6. BIRTHPLACE (City and State or Foreign Country)

4c. UNDER 1 DAY

Days

STATE FILE NO.
3. SOCIAL SECURITY NUMBER

F

4b. UNDER 1 YEAR

7a. RESIDENCE-STATE

To Be Completed/ Verified By:
FUNERAL DIRECTOR:

NAME OF DECEDENT ____________________________________________
For use by physician or institution

LOCAL FILE NO.
1. DECEDENT’S LEGAL NAME (Include AKA’s if any) (First, Middle, Last)

7f. ZIP CODE

9. MARITAL STATUS AT TIME OF DEATH
Married
Married, but separated
Widowed
Divorced
Never Married
Unknown

7g. INSIDE CITY LIMITS?

Yes

No

10. SURVIVING SPOUSE’S NAME (If wife, give name prior to first marriage)

11. FATHER’S NAME (First, Middle, Last)

12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)

13a. INFORMANT’S NAME

13c. MAILING ADDRESS (Street and Number, City, State, Zip Code)

13b. RELATIONSHIP TO DECEDENT

14. PLACE OF DEATH (Check only one: see instructions)
IF DEATH OCCURRED IN A HOSPITAL:
Inpatient
Emergency Room/Outpatient
Dead on Arrival
15. FACILITY NAME (If not institution, give street & number)

18. METHOD OF DISPOSITION:
Burial
Cremation
Donation
Entombment
Removal from State
Other (Specify):_____________________________
20. LOCATION-CITY, TOWN, AND STATE

IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
Hospice facility
Nursing home/Long term care facility
Decedent’s home
16. CITY OR TOWN , STATE, AND ZIP CODE

Other (Specify):
17. COUNTY OF DEATH

19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)

21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY

22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER AGENT

23. LICENSE NUMBER (Of Licensee)
24. DATE PRONOUNCED DEAD (Mo/Day/Yr)

ITEMS 24-28 MUST BE COMPLETED BY PERSON
WHO PRONOUNCES OR CERTIFIES DEATH

26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable)
29. ACTUAL OR PRESUMED DATE OF DEATH
(Mo/Day/Yr) (Spell Month)

25. TIME PRONOUNCED DEAD

27. LICENSE NUMBER

28. DATE SIGNED (Mo/Day/Yr)

30. ACTUAL OR PRESUMED TIME OF DEATH

31. WAS MEDICAL EXAMINER OR
CORONER CONTACTED?
Yes

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
IMMEDIATE CAUSE (Final disease or condition ---------> resulting in death)

No

Approximate interval: Onset to death

CAUSE OF DEATH (See instructions and examples)

a._____________________________________________________________________________________________________________
Due to (or as a consequence of):
b._____________________________________________________________________________________________________________
Due to (or as a consequence of):

_____________

c._____________________________________________________________________________________________________________
Due to (or as a consequence of):

_____________

d._____________________________________________________________________________________________________________

Sequentially list conditions, if any, leading to the cause listed on line a. Enter the
UNDERLYING CAUSE
(disease or injury that initiated the events resulting in death) LAST

_____________

_____________

To Be Completed By:
MEDICAL CERTIFIER

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

35.

DID TOBACCO USE CONTRIBUTE
TO DEATH?