NCHS publishes this model certificate, and each state's paper death certificate and electronic death registration system follows its content; the 2003 revision was in use in all states by 2018. Clinicians meet it when a patient dies under their care: they pronounce death or certify the cause and manner in items 24 to 49, and the funeral director files the record with the registrar.
The attending physician, other medical certifiers such as NPs or PAs where state law allows, or a medical examiner or coroner completes the medical items, with a pronouncing physician completing items 24 to 28 when the certifier is unavailable at death. The funeral director completes the personal items with an informant, usually a family member.
Enter the date and time pronounced dead, spelling out the month and using a 24-hour clock. Items 26 to 28, the pronouncer's signature, license number and date signed, are used only when the physician responsible for the cause of death is unavailable at the time of death and state law allows a separate pronouncer. A certifier who completes items 24 and 25 plus 29 to 49 may leave items 26 to 28 blank.
Give the actual or presumed date and time of death. If the exact date is unknown, enter an approximate date; if it cannot be approximated, enter the date the body was found and identify it as the date found. Estimated times may be written with Approx. before them. Item 31 asks whether the medical examiner or coroner was contacted.
Line a, the immediate cause, must always have an entry. Put the condition that caused line a on line b, and so on, with the underlying cause (the disease or injury that started the chain) on the lowest line used. Enter one cause per line, do not abbreviate, and add lines if needed. Give an onset-to-death interval for each line; unknown, approximately, or general terms such as hours or days are acceptable, but not a blank. For neoplasms, state primary site, behavior, cell type, grade and part of organ.
List diseases or conditions that contributed to death but were not part of the Part I sequence and did not result in the underlying cause, such as diabetes or chronic obstructive pulmonary disease in the cardiac example on the form. If two sequences could each have caused death, report in Part I the one that most directly caused it and the other in Part II.
Item 33: enter Yes if a partial or full autopsy was performed; otherwise No. Item 34: enter Yes if the autopsy findings were available to complete the cause of death, or No if not; leave it blank when no autopsy was performed. If findings arrive later and change the cause, submit a supplemental report of cause of death.
Item 35: check Yes, Probably, No or Unknown for whether tobacco use contributed to death, using clinical judgment; it often contributes to deaths from emphysema, lung cancer, some heart disease and head and neck cancers. Item 36, for females, records pregnancy status: not pregnant within the past year, pregnant at death, pregnant within 42 days, pregnant 43 days to 1 year before death, or unknown. It is used to identify pregnancy-related mortality.
Always check one: Natural, Accident, Suicide, Homicide, Pending Investigation or Could Not Be Determined. Manner matters for accurate cause-of-death coding, insurance claims and injury statistics. Use Pending Investigation when accident, suicide or homicide cannot be decided within the filing time limit, and change it later. Use Could Not Be Determined only when determination is impossible.
Complete these for every death due to injury or poisoning. Spell out the month for the date of injury, which may differ from the date of death, and give the time on a 24-hour clock. Describe the general place (factory, not a company name), whether the injury was at work, the full address, and a brief, specific account of how it happened, including vehicle type. For transportation injuries, mark driver/operator, passenger, pedestrian or other.
Check one certifier statement: certifying physician, pronouncing and certifying physician, or medical examiner/coroner, and sign. Rubber stamps and facsimile signatures are not accepted on paper certificates, though states with electronic systems may authenticate differently. Then give the name, address and zip code of the person who completed the cause of death, the certifier's title, license number and the date certified.
Download the current version from the source each time; forms change without notice.
U.S. Standard Certificate of Death
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A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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It depends on the state. The NCHS Physician's Handbook addresses physicians and other medical certifiers, naming physician assistants and nurse practitioners, depending on state or local laws and rules. The certifier box in item 45 on the model form lists the certifying physician, the pronouncing and certifying physician, and the medical examiner or coroner, and state versions of the certificate may differ.
Do not enter a terminal event such as cardiac arrest, respiratory arrest or ventricular fibrillation without showing the etiology. If a mechanism of death seems right for line a, list its cause on the lines below, for example cardiac arrest due to coronary artery atherosclerosis. Organ failure, sepsis and similar processes also need their underlying cause reported beneath them.
Per the NCHS handbook, a pronouncing physician completes items 24 to 31. A certifying physician completes 32 to 37 and 45 to 49. A physician who both pronounces and certifies completes 24, 25, 29 to 37 and 45 to 49. A medical examiner or coroner completes 24, 25, 29, 30 and 32 to 49. Injury items 38 to 44 are added when an injury is involved.
Check Pending Investigation when it cannot be determined, within the statutory time limit for filing, whether the death was an accident, suicide or homicide; it must later be changed to one of the other terms. Could Not Be Determined is used only when it is impossible to determine the manner. Most deaths are Natural.