U.S. Death Certification Laws by State

Completing the death certificate is the last act of care for a patient and provides closure for the family. On an individual case level, death certificates are used to settle estate and other legal matters, obtain insurance and/or pension benefits, and, importantly, to allow funeral homes to proceed with burial or cremation.

Furthermore, information from the death certificate, including the cause of death, is used in official mortality statistics including life expectancy, leading causes of death, infant and maternal mortality rates, and information regarding death rates by cause of death, socio-demographic characteristics and geographic area. As a result, mortality statistics are used to assess the general health of the population, track disease trends, develop public health and safety initiatives, examine medical problems which may be unique to specific groups of people, identify areas of research that will reduce mortality and allocate medical services, funding, and other resources.

The death certificate should ideally be completed by the attending physician (sometimes advanced practice nurse practitioner) who last cared for the patient. This is often not the same physician who made the death pronouncement. For patients who die in the hospital, this is typically the primary attending physician treating them during their hospitalization. In other cases, such as patient’s who die in the emergency room or at home, the patient’s primary care physician may be the most appropriate certifier. If attending physician is not available or a viable option, another licensed physician involved in the patient’s care may be considered.  Additionally, if the circumstances surrounding the patient’s death require coroner or medical examiner intervention, they will likely sign the death certificate.

One of the most common misconceptions regarding death certification, is that signing the death certificate imposes liability on the death certifier. In fact, however, the death certificate is an opinion based on information available at the time the death certificate is completed and requires only that the implicated disease process is more likely the cause of death than not (>50% probability). Qualifiers such as ‘probably’ or ‘presumed’ are acceptable if there is any element of uncertainty. Lawsuits against certifiers of death are extremely rare, and the certifier is usually upheld when they do occur. Furthermore, death certificates can be amended, if necessary, particularly if an autopsy is performed and uncovers significant findings.

Cause of death definitions

• Underlying cause of death (bottom line of Part I of DC): The etiologically specific disease or injury which begins the lethal sequence of events, without sufficient intervening causes.
• Immediate cause of death (top line of Part I of DC): The final disease or condition that results directly in death (e.g. occurred closest to time of death). It can be the only entry if that condition is the sole cause of death. It should not include the mechanism of death or terminal event (e.g. cardiac arrest).
• Intermediate cause of death: A disease or condition that occurs between the underlying cause and the immediate cause of death

Each cause of death should be recorded with as much specificity as possible and general duration (e.g. days, weeks, months, years, etc.) provided.

Manner of death

The manner of death is the categorical classification of the type of death. Categories include: natural, accident, homicide, suicide, pending investigation and cannot be determined. Of note, only natural deaths should be certified by non-medical examiner/non-coroner physicians.

Natural deaths are those that result solely from disease and/or age. Accidental deaths are deaths in which unintentional injury or poisoning contributed to or caused death. Deaths are categorized as suicides or homicides when death occurs due to volitional injury or poisoning by oneself or another, respectively. The “pending investigation” category is utilized in situations in which the manner cannot be determined within the statutory time limit for signing the death certificate, and should be changed once further information is available. Deaths should only be categorized as “cannot be determined” if there is insufficient information for classification, even after appropriate investigation. 

Completing the death certificate

Death registration is controlled by individual state or local laws and regulations, and death certificates are stored according to state practice. However, each state has a contract with the National Center for Health Statistics (NCHS) that allows collation of death information in order to produce national vital statistics. In an effort to streamline this data collection, NCHS has developed, and periodically revises, a standard death certificate for states to use as a template. Although most state death certificates are similar to the standard US death certificate, minor changes may been seen from state-to-state.

Each death certificate generally contains three major sections: demographics/statistics, disposition and information relating to the patient’s death, the first two of which are generally completed by the funeral director. If the person who pronounced the patient’s death is different than the certifier of death, the pronouncer must complete the portion of the death certificate pertaining to the pronouncement. The remainder of the medically relevant information is then completed by the certifier. There are two main sections pertaining to the patient’s cause of death. Part I is intended to delineate the chain of events that led directly to the patient’s death, beginning with the most immediate and working backward to the underlying cause of death. Each condition should be listed on separate lines with the underlying cause of death listed on the lowest used line in Part I. An estimate of the interval between the onset (not diagnosis) of each condition and death should also be reported. Part II is used to report all conditions that contributed to death but were not mentioned in Part I. Conditions should be separated by a comma or semi-colon.

If additional information becomes available that would change the cause of death from that originally reported, the death certificate should be amended immediately.

Common mistakes

One of the most common mistakes in completing the death certificate is lack of specificity; the cause of death should be as specific as possible. For example, instead of simply listing “sepsis” as a cause of death, “sepsis in the setting of E. coli bacteremia, due to bowel ischemia and perforation” is a more appropriate cause of death. Another is inappropriate use of “cardiopulmonary arrest”; this is synonymous with death, not a cause of death. Misuse of contributory conditions is also common in completion of death certificates. Contributory conditions are only those which made physiologic contribution to death; it is not simply a reiteration of the problem list.

A handful of articles have been written over the years that shed some light on the frequency and cause of errors in death reporting. Pritt et al report that although the criteria used to define “major errors” varied between studies, the rate of major errors across various institutions has been reported as 24-37%. Jordan and Bass write that, in their institution, death certificates were completed in an “acceptable fashion” only 68.1% of the time. As a way of countering this, some institutions have created death certification learning modules that are provided to their practitioners and others heavily involve their pathology colleagues in death certification handling and/or review. In an effort to promote pathology-driven education and consultation, we hope that this short overview and guide to additional resources will serve as a bridge to more efficient and accurate death reporting.

General rules:

1. If reporting on paper, write using black ink
2. Avoid abbreviations
3. Report time as 24-hour/military time; when entering dates, enter the full name of the month
4. If organ failure is listed as a cause of death, always include the etiology as an underlying cause
5. If malignancy is list as a cause of death, always include primary site, benign or malignant, cell type, grade and part or lobe of organ affected
6. If an infectious disease is listed as a cause of death, include the specific organism

Information is for non-fetal decedents only (specific circumstances for fetal in many states). Deaths certified by ME/coroner may not be held to same requirements. Information verified/updated annually so access state government website for most up-to-date information.

Resources

1. US Standard Certificate of Death: https://www.cdc.gov/nchs/data/dvs/death11-03final-acc.pdf
2. Centers for Disease Control: https://www.cdc.gov/nchs/nvss/writing-cause-of-death-statements.htm
3. National Center for Health Statistics. Physician’s handbook on medical certification of death. Hyattsville, MD: National Center for health Statistics. 2023. DOI: https://dx.doi.org/10.15620/cdc:131005 

1. Brooks EG, Reed KD. Principles and Pitfalls: a Guide to Death Certification. Clin Med Res. 2015 13(2):74-82. doi:10.3121/cmr.2015.1276
2. DeJoseph M, Gill JR. Death certificates and death investigations in the United States. UpToDate
3. Jordan JM, Bass MJ. Errors in death certificate completion in a teaching hospital. Clin Invest Med. 1993 Aug; 16(4):249-255.
4. Pape A, Scherpelz KP. Frequency and types of errors in clinician-composed death certificates for patients with or without autopsy in a hospital propulsion. J Public Health (Oxf.) 2024 Feb 23;;46(1):83-86. doi:10.1093/pubmed/fdad255
5. Pritt BS, Hardin NJ, Richmond JA, Shapiro SL. Death Ccertification error at an academic institution. Arch Pathol Lab Med. 2005 Nov; 129(11):1476-1479. doi:10.5858/2005-129-1476-DCEAAA
6. Schuppener MLLM, Olson K, Brooks EG. Death Certification: Errors and Interventions. Clin Med Res. 2020 Mar; 18(1):21-26. doi:10.3121/cmr.2019.1496
7. https://www.cdc.gov/nchs/nvss/writing-cause-of-death-statements.htm