Death Certificate Vr2001 P1 VR200 2pages
User Manual: VR200
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STATE OF ILLINOIS CERTIFICATE OF DEATH REGISTRATION DISTRICT NO. LOCAL FILE NUMBER STATE FILE NUMBER 1. DECEDENT'S LEGAL NAME (Include AKAs if any) (First, Middle, Last) 4. COUNTY OF DEATH 2. SEX 5a. AGE AT LAST BIRTHDAY (Years) 5b. UNDER 1 YEAR Months Days 7a. CITY OR TOWN 5c. UNDER 1 DAY Hours Minutes 3. DATE OF DEATH (Month/Day/Year) (Spell Month) 6. DATE OF BIRTH (Month/Day/Year) 7b. HOSPITAL OR OTHER INSTITUTION NAME (If not in either, give street and number) 7c. PLACE OF DEATH (Check only one: see instructions) IF DEATH OCCURRED IN A HOSPITAL Inpatient Emergency Room/Outpatient 8. BIRTHPLACE (City and State or Foreign Country) Dead on Arrival 13b. APT. NO. 13f. STATE 13g. ZIP CODE Nursing Home/Long-term care facility 10. MARITAL STATUS AT TIME OF DEATH Married Divorced 16a. INFORMANT'S NAME Illinois Department of Public Health - Division of Vital Records Hospice facility 9. SOCIAL SECURITY NUMBER 13a. RESIDENCE (Street and Number) 13e. COUNTY IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL Married but separated Never Married Widowed Unknown Other (Specify): Yes 13c. CITY OR TOWN No 13d. INSIDE CITY LIMITS? Yes 14. FATHER'S NAME (First, Middle, Last) 16b. RELATIONSHIP 17. METHOD OF DISPOSITION: Burial Cremation Donation Entombment Decedent's home 11. SURVIVING SPOUSE'S NAME 12. EVER IN U.S. (If wife, give full name prior to first marriage) ARMED FORCES? No 15. MOTHER'S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last) 16c. MAILING ADDRESS (Street and No., City or Town, State, Zip Code) 18. PLACE OF DISPOSITION (Name of cemetery, crematory, other) Cremation 19. LOCATION - CITY, TOWN AND STATE 20. DATE OF DISPOSITION (Month/Day/Year) Other (Specify): 21a. FUNERAL HOME STREET AND NUMBER NAME CITY OR TOWN STATE ZIP 21b. FUNERAL DIRECTOR'S SIGNATURE 21c. FUNERAL DIRECTOR'S ILLINOIS LICENSE NUMBER 22. LOCAL REGISTRAR'S SIGNATURE 23. DATE FILED WITH LOCAL REGISTRAR (Month/Day/Year) CAUSE OF DEATH (See instructions and examples) APPROXIMATE INTERVAL BETWEEN ONSET AND DEATH 24. 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 etiology. If the decedent had a dementia related disease. Parkinson's Disease, or Parkinson Dementia Complex, indicate in Part I or Part II. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE (Final disease or condition resulting in death) a. Due to (or as a consequence of): Sequentially list conditions, if any, leading to the cause listed b. on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated the events c. resulting in death) LAST Due to (or as a consequence of): Due to (or as a consequence of): PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I. 25. WAS AN AUTOPSY PERFORMED? Yes No VR200 (Rev. 1/08) 26. WERE AUTOPSY FINDINGS USED TO Yes COMPLETE CAUSE OF DEATH? 27. DID TOBACCO USE CONTRIBUTE TO DEATH? Yes No Probably Unknown 28. IF FEMALE: Not pregnant within past 12 months Not pregnant, but pregnant within 42 days of death Not pregnant, but pregnant 43 days to 1 year before death 30. DATE OF INJURY (Month/Day/Year) 34. LOCATION OF INJURY 31. TIME OF INJURY A.M. Street and Number P.M. 29. MANNER OF DEATH Pregnant at time of death Pregnant within one year of death but time unknown Unknown if pregnant within the past 12 months Suicide Homicide Could not be determined Pending Investigation 33. INJURY AT WORK? 32. PLACE OF INJURY (e.g. Decedent's home; construction site;restaurant;wooded area) Apartment Number City or Town 35. DESCRIBE HOW INJURY OCCURRED: 37. I (DID) (DID NOT) ATTEND THE DECEASED AND LAST SAW HIM/HER ALIVE ON Natural Accident No Yes State No ZIP Code 36. IF TRANSPORTATION INJURY, SPECIFY: Driver/Operator Pedestrian Passenger Other (Specify): (Month/Day/Year) 38. WAS MEDICAL EXAMINER OR CORONER CONTACTED? Yes No 39. DATE PRONOUNCED (Month/Day/Year) 40. TIME OF DEATH A.M. P.M. 41. CERTIFIER (Check only one): Physician in charge of patient's care: To the best of my knowledge, death occurred due to the cause(s) and manner stated. Physician in attendance at the time of death only: To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated. Medical Examiner/Coroner: On the basis of examination and/or investigation, in my opinion, death occurred at the time, date and place, and due to the cause(s) and manner stated. 42. NAME, ADDRESS AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 24) 43. PHYSICIAN'S LICENSE NUMBER 44. TITLE OF CERTIFIER 47. DECEDENT'S EDUCATION - Check the box that best describes the highest degree or level of school completed at the time of death. 45. DATE CERTIFIED (Month/Day/Year) 48. DECEDENT OF HISPANIC ORIGIN? - Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check the "No" box if decedent is not Spanish/Hispanic/Latino. 8th grade or less No, not Spanish/Hispanic/Latino 9th - 12 grade; no diploma Yes, Mexican, Mexican American, Chicano High school graduate or GED completed Yes, Puerto Rican Some college credit, but no degree Yes, Cuban Associated degree(e.g. AA, AS) Yes, other Spanish/Hispanic/Latino Bachelor's degree(e.g. BA, AB, BS) Master's degree(e.g. MA, MS, MEng, MEd, MSW, MBA) Specify: MD, DDS, DVM, LLB, JD) Doctorate(e.g. PhD, EdD) or Professional degree(e.g. Unknown 46. SIGNATURE OF CERTIFIER 49. DECEDENT'S RACE - Check one or more races to indicate what the decedent considered himself or herself to be. White Black or African American American Indian or Alaskan Native (Name of the enrolled or principle tribe) Asian Indian Chinese Vietnamese Other Asian(Specify) Native Hawaiian Filipino Japanese Guamanian or Chamorro Korean Samoan Other Pacific Islander(Specify) Other(Specify) 50. DECEDENT'S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED). 51. BUSINESS/INDUSTRY (Enter type of business or industry, NOT COMPANY NAME) Printed by the Authority of the State of Illinois P.O. #148109 150M 7/07
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