Professional Documents
Culture Documents
State of Texas Certificate of Death
State of Texas Certificate of Death
1. LEGAL NAME OF DECEASED (Include AKA's, if any) (First, Middle, Last) (Maiden) 2. DATE OF DEATH - ACTUAL OR PRESUMED
3. SEX 4. DATE OF BIRTH 5. AGE-Last Birthday IF UNDER 1 YR IF UNDER 1 DAY 6. BIRTHPLACE (City & State or Foreign Country)
(Years) MO DAYS HOURS MIN
Male March 23 1994 30
7. SOCIAL SECURITY NUMBER 8. MARITAL STATUS AT TIME OF DEATH 9. SURVIVING SPOUSE'S NAME (If Wife, give name prior to first marriage)
✔ Married
Widowed Divorced Never Married Unknown
467963854 Whitney Pearl
10a. RESIDENCE STREET ADDRESS 10b. APT. NO. 10c. CITY OR TOWN
10d. COUNTY 10e. STATE 10f. ZIP CODE 10g. INSIDE CITY LIMITS?
24. NAME OF FUNERAL FACILITY 25. COMPLETE ADDRESS OF FUNERAL FACILITY (Street and Number, City State, Zip Code)
TERMINAL EVENTS SUCH AS CARDIAC ARREST, RESPIRATORY ARREST, OR VENTRICULAR FIBRILLATION WITHOUT SHOWING THE Onset to death
ETIOLOGY. DO NOT ABBREVIATE. ENTER ONLY ONE CAUSE ON EACH LINE
CAUSE OF DEATH
d. Diabetes
PART 2. ENTER OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE UNDERLYING 34. WAS AN AUTOPSY PERFORMED?
CAUSE GIVEN IN PART I.
Yes No
35. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH?
Yes No
36. MANNER OF DEATH 37. DID TOBACCO USE 38. IF FEMALE: 39. IF TRANSPORTATION INJURY, SPECIFY:
Natural CONTRIBUTE TO DEATH? Driver/Operator
Not pregnant within past year
Accident Yes Passenger
Pregnant at time of death
Suicide No Pedestrian
Not pregnant, but pregnant within 42 days of death
Homicide Probably Other (Specify)
Not pregnant, but pregnant 43 days to one year before death
Pending Investigation Unknown
Unknown if pregnant within the past year
Could not be determined
40a. DATE OF INJURY (Mo/Day/Yr) 40b. TIME OF INJURY 40c. INJURY AT WORK? 40d. PLACE OF INJURY (e.g, Decedent's home, construction site, restaurant, wooded area)
Yes No
VS-112 REV 1/2006
40e. LOCATION (Street and Number, City,State,Zip Code) 40f. COUNTY OF INJURY
42a. REGISTRAR FILE NO. 42b. DATE RECEIVED BY LOCAL REGISTRAR 42c. REGISTRAR
46. EVER IN U.S. ARMED FORCES? Yes ✔ No 47. EVER A PEACE OFFICER IN THIS STATE? Yes ✔ No Other (Specify)
48. DECEDENT'S USUAL OCCUPATION (Indicate type of work done during 49. TYPE OF BUISNESS/INDUSTRY
most of working life. DO NOT USE RETIRED)
Nurse Health
IF DECEASED SERVED IN U.S. ARMED FORCES, FILL OUT THE FOLLOWING:
Is the deceased reported to have been in such service? Name of organization in which service was rendered?
Serial number of discharge papers or adjusted service certificate? Name of next of kin or of next friend?
James Smith
Post Office Address?
All information except signatures should be typed. If it is not possible to type the information, print
legibly using durable black or blue ink. All signatures must be handwritten in durable black or blue
ink (unless signed electronically in Texas Electronic Registrar described below). Rubber stamps or
facsimile signatures are not permitted [HSC §191.025(d)] for funeral directors and certifiers.
Complete each item following the requirements for that specific item. These instructions can be
found online at www.dshs.state.tx.us/vs/fie/d/handbooks/deacont.shtm or in the Texas Vital Statistics
Handbook on Death Registration.
Do not leave a space blank unless specifically instructed to do so. Avoid using correction fluid. Do
not make alterations, erasures, or strike-overs. Obvious changes affect the validity of a certificate.
Altered certificates may be rejected by the local registrar or Texas Vital Statistics. Avoid
abbreviations except for those suggested in the item-by-item specific instructions. Verify the spelling
of all names and numbers with the informant.
A Certificate of Death must be filed within ten (10) days of the date of death for every death in
Texas. It must be filed with the local registrar in the district where the death occurred or the body
was found [HSC §193.003(a)].
The Certificate of Death must be filed by the person in charge of interment or disposition, or by the
person in charge of removing the body from the registration district for disposition [HSC § 193.002].
The certifier is responsible for verifying the date of death in Item 2 and completing the medical
certification portion of the Texas Certificate of Death (Items 26 through 39). The certifier must
complete the medical certification not later than five (5) days after receiving the record or provide
notification to the funeral director, or person acting as such, explaining the reason for the delay [HSC
§193.005(b)(g)].
If the manner of death is other than natural, the justice of the peace or medical examiner should be
called immediately. Physicians should not certify suicides, homicides, or accidental deaths. A
medical examiner should also be notified if a death occurs within 24 hours of admission to a hospital
(regardless of the manner of death).
A current death certificate can only be filed within one year of the date of death. If a death certificate
has not been filed within one (1) year, a Court-Ordered Delayed Certificate of Death should be filed.
If the cause of death is pending investigation, the certifier should enter "Pending Investigation" and
file the certificate immediately. Upon determination of the cause of death, an Amendment to Medical
Certification of Certificate of Death (VS-174) should be filed by the physician, medical examiner, or
justice of the peace who originally certified the death.
TEXASElectronic
REGISTRAR
TER (Texas Electronic Registration) - Death is a free online Internet death registration system available through the
Texas Vital Statistics office. A user can start and complete his or her portion of the Certificate of Death without having to
leave the office or wait for the other parties to complete their portions.
Licensed funeral directors, physicians, justices of the peace, medical examiners, and local registrars may complete their
portion of the Certificate of Death and electronically sign it at their own computer. Timeliness prompts will warn users to
complete their portion so that the Certificate of Death will be filed in a timely matter. The Social Security number of the
deceased is verified by the Social Security Administration in real-time. A Report of Death is sent electronically to the
local registrar and funeral directors may print a paper copy of that report for themselves.