Handbook on Death REgistration

2019

[HANDBOOK ON DEATH

REGISTRATION]

Department of State Health Services Vital Statistics Section

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CONTENTS 
Introduction ............................................................................................................................................................................... 4 
Registration Requirements ............................................................................................................................................. 5 
Responsibilities of the Funeral Director or Person Acting as Such................................................................ 5 
The funeral director or person acting as such is responsible for: ............................................................. 5 
Additional responsibilities of the funeral director or person acting as such: ...................................... 6 
Certifying Death................................................................................................................................................................... 7 
General Information ..................................................................................................................................................... 7 
Deaths Certified by the Attending Physician ...................................................................................................... 8 
Deaths Certified by the Medical Examiner or Justice of the Peace ............................................................ 8 
Deaths Certified by the County Judge .................................................................................................................... 9 
Death of a Child Less than Six (6) Years of Age ................................................................................................. 9 
Unidentified Persons .................................................................................................................................................... 9 
If remains are found.................................................................................................................................................... 10 
Missing or Unrecognizable Remains .................................................................................................................... 10 
Confidentiality of Information ................................................................................................................................ 10 
Penalties .......................................................................................................................................................................... 10 
Instructions for Completing a Certificate of Death ............................................................................................. 11 
General Instructions for Death Certificates ...................................................................................................... 11 
Death Certificate Paper Specifications ..................................................................................................................... 11 
Amending the Certificate of Death ................................................................................................................................. 12 
Introduction ........................................................................................................................................................................ 12 
Procedures for Amending Certificate of Death..................................................................................................... 12 
PART I ............................................................................................................................................................................... 13 
PART II.............................................................................................................................................................................. 13 
PART III ............................................................................................................................................................................ 13 
Documentation ............................................................................................................................................................. 13 
Filing Medical Amendments ......................................................................................................................................... 13 
Instructions for Completing a Medical Amendment  .................................................................................... 14 
Authorizations ................................................................................................................................................................... 15 
Report of Death Form (VS-115) ............................................................................................................................. 15 
Burial-Transit Permit (VS-116) ............................................................................................................................. 15 
Transporting a Body to a Foreign Country........................................................................................................ 16 
Mexico ............................................................................................................................................................................. 16 

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Countries Other than Mexico ............................................................................................................................ 16 
Authorization for Cremation ................................................................................................................................... 16 
Disinterment Permit (VS-2219)............................................................................................................................. 17 
Instructions for Completing the Application for a Disinterment Permit (VS-271) .......................... 18 
Please type or print except where signatures are required. Names may be typed beneath 
the signature for clarification. .......................................................................................................................... 18 
Instructions for Completing the Disinterment Consent Form (VS-271.1) ........................................... 18 
Delayed Registration of Death ..................................................................................................................................... 19 
Overview.......................................................................................................................................................................... 19 
Death Registration by Judicial Order ................................................................................................................... 20 
Item-by-Item Instructions.............................................................................................................................................. 21 
1. Legal Name of decedent (Include AKAs If Any) (first, middle, last): ...................................................... 21 
2. Date of Death: ................................................................................................................................................................ 22 
3. Sex: ..................................................................................................................................................................................... 23 
4. Date of Birth: .................................................................................................................................................................. 23 
5. Age: .................................................................................................................................................................................... 23 
6. Birthplace (City & State or Foreign Country): .................................................................................................. 23 
7. Social Security Number: ............................................................................................................................................ 24 
8. Marital Status: ............................................................................................................................................................... 24 
9. Surviving Spouse (If Wife, Give Name Prior to First Marriage): ............................................................... 25 
10. Residence: .................................................................................................................................................................... 25 
Residence Street Address [10a] ............................................................................................................................. 25 
Apt. No. [10b] ................................................................................................................................................................. 26 
City or Town [10c] ....................................................................................................................................................... 26 
County [10d] .................................................................................................................................................................. 26 
State [10e] ....................................................................................................................................................................... 26 
Zip Code [10f] ................................................................................................................................................................ 27 
Inside City Limits [10g] ............................................................................................................................................. 27 
11. Father's Name: ............................................................................................................................................................ 27 
12. Mother's Maiden Name: .......................................................................................................................................... 27 
13. Place of Death (Check Only One): ....................................................................................................................... 27 
Hospital deaths: ............................................................................................................................................................ 28 
Non-hospital deaths: .................................................................................................................................................. 28 
14. County of Death: ........................................................................................................................................................ 29 
15. City or Town, Zip (If Outside City Limits, Give Precinct No.) .................................................................. 29 

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16. Facility Name (if not institution, give street address): .............................................................................. 29 
17. Informant's Name & Relationship To decedent ............................................................................................ 30 
18. Mailing Address of Informant (Street and Number, City, State, and Zip Code) ............................... 30 
19. Method of Disposition ............................................................................................................................................. 30 
20. Signature of Funeral Director or Person Acting as Such ........................................................................... 31 
21. Unknown, Section, Block, Lot, Space ................................................................................................................. 31 
22. Place of Disposition (Name of Cemetery, Crematory, or Other Place) ................................................ 31 
23. Location (City/Town, and State) ......................................................................................................................... 32 
24. Name of Funeral Facility ........................................................................................................................................ 32 
25. Complete Address of Funeral Facility (Street and Number, City, State, Zip Code): ....................... 32 
26. Certifier.......................................................................................................................................................................... 32 
27. Signature of Certifier ................................................................................................................................................ 32 
28. Date Signed (Month Day Year) ............................................................................................................................ 32 
29. License Number ......................................................................................................................................................... 33 
30. Time of Death (Actual or Presumed) ................................................................................................................ 33 
31. Printed Name, Address of Certifier (Street and Number, City, State, Zip Code) ............................. 33 
32. Title of Certifier: ......................................................................................................................................................... 33 
33. Cause of Death ............................................................................................................................................................ 33 
Part 1. 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 Each Line: .................................................................................................................................................... 34 
Part 2. Enter Other Significant Conditions Contributing To Death But Not Resulting In The 
Underlying Cause Given In Part 1 ......................................................................................................................... 35 
34. Was An Autopsy Performed?: .............................................................................................................................. 35 
35. Were Autopsy Findings Available to Completion of Cause of Death? .................................................. 35 
36. Manner of Death ........................................................................................................................................................ 35 
37. Did Tobacco Use Contribute to Death? ............................................................................................................. 36 
38. If Female: ...................................................................................................................................................................... 36 
Items 39 through 41- Injury Information:.............................................................................................................. 36 
39. If Transportation Injury, Specify: ................................................................................................................... 36 
40a. Date of Injury (Mo/Day/YYYY): ................................................................................................................... 37 
40b. Time of Injury: ..................................................................................................................................................... 37 
40c. Injury at Work? ................................................................................................................................................... 37 
40d. Place of Injury (e.g. Decedent's Home, Construction Site, Restaurant, Wooded Area): ....... 38 
40e. Location (Street and Number or Rural Route, City or Town, State): ............................................ 38 

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40f. County of Injury: .................................................................................................................................................. 38 
41. Describe How Injury Occurred: ...................................................................................................................... 38 
42A-C: Local Registrar File Information ................................................................................................................. 39 
42a. Registrar File Number ...................................................................................................................................... 39 
42b. Date Received by Local Registrar: .............................................................................................................. 39 
42c. Registrar: ............................................................................................................................................................... 39 
Items 43 through 49: ....................................................................................................................................................... 39 
43. Decedent's Education: ........................................................................................................................................ 40 
Check the box that best describes the highest degree of level of school completed at the time of 
death. ................................................................................................................................................................................. 40 
44. Decedent of Hispanic Origin? .......................................................................................................................... 40 
45. Decedent's Race: ................................................................................................................................................... 40 
46. Ever in U.S. Armed Forces? ............................................................................................................................... 41 
47. Ever a Peace Officer in This State? ................................................................................................................ 41 
48. Decedent's Usual Occupation: ......................................................................................................................... 41 
49. Type of Business/Industry ............................................................................................................................... 42 
 
 
CHAPTER ONE 
INTRODUCTION  
This handbook describes death registration in the Texas vital registration system. It provides 
instructions for completing and filing death certificates along with related permits.  
A death certificate is a permanent legal record of an individual's death and is extremely important 
to the family of the deceased person. The information recorded on the death certificate is used for 
application of insurance benefits, settlement of pension claims, and to transfer title of real and 
personal property. Information recorded on a death certificate provides evidence of the fact of 
death and can be produced as evidence in a court of law.  
The death certificate provides important information data on mortality that is used in a variety of 
medical and health-related research efforts. Mortality statistics identify the causes of death and 
help evaluate diagnostic and therapeutic techniques. These statistics are used to assess the general 
health of Texas citizens. Mortality statistics also help identify diseases found among specific groups 
of people and determines where medical research may have the greatest impact on reducing 
mortality. Statistical information is also used to allocate medical and nursing services and to follow 
the course of infectious diseases.  

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Because mortality statistics are no more accurate than the information submitted on death 
certificates, it is very important that all death certificates be completed and filed with accuracy and 
promptness.  
REGISTRATION REQUIREMENTS  
A Certificate of Death (VS-112) 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 funeral director, or person acting as such, 
shall obtain an electronically filed report of death through Vital Statistics Section TxEVER 
Registration system or complete a report of death before transporting the body. The report of death 
shall within 24 hours be mailed or otherwise transmitted to the local registrar of the district in 
which the death occurred or in which the body was found. A copy of the completed or electronically 
filed report of death as prescribed by the Vital Statistics Section shall serve as authority to transport 
or bury the body or fetus within this state. [25 TAC 181.2(a)].  
The death certificate must be filed electronically, as specified by the state registrar, 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]. When arrangements for disposition of a body are 
made through a funeral home, a death certificate should be completed and filed by the funeral 
director. When a body has been donated to a hospital, medical school, or mortuary school for 
scientific or educational purposes, the institution is responsible for completing and filing the 
Certificate of Death.  
RESPONSIBILITIES OF THE FUNERAL DIRECTOR OR PERSON ACTING AS SUCH  
Death registration requires a cooperative effort between the funeral director or other person 
accepting responsibility for disposition of the body; the certifier of the cause of death, which may be 
the physician that attended the deceased, the medical examiner, or the justice of the peace, 
depending on the circumstances of the death; and the informant who provides personal, non-
medical information about the deceased.  
THE FUNERAL DIRECTOR OR PERSON ACTING AS SUCH IS RESPONSIBLE FOR:  
  Filing a Report of Death with the local registrar within 24 hours of taking custody of the 
body. This may be by mail mailed or otherwise transmitted to the local registrar [25 TAC 
181.2(a)].  
  Completing all items on the death certificate and obtaining the required information from 
the person best qualified to furnish the information.  
The funeral director or person acting as such should notify the medical examiner or justice of the 
peace for investigation or inquest and cause of death certification if law enforcement or someone 
else has not already done so if any of the following circumstances exist [HSC 193.005, CCP Art. 
49.04, CCP Art. 49.25 Sec. 6]:  
  A body was found and the cause and circumstances of the death are unknown.  

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 The death is believed to be an unnatural death from a cause other than a legal execution

(accident, suicide, or homicide).

 The death occurred in prison or in jail.

 The death occurred within 24 hours of admission to a hospital (refer to a medical examiner

only CCP Art. 49.25 Sec. 6 (1) ).

 The death occurred without medical attendance.

 The physician is unable or unwilling to certify the cause of death.

 The deceased is under six (6) years of age.

ADDITIONAL RESPONSIBILITIES OF THE FUNERAL DIRECTOR OR PERSON ACTING AS

SUCH:

 Cooperate with pathologists in cases involving autopsies.

 Obtain the cause of death information from the attending physician, the medical examiner,

or the justice of the peace as appropriate based upon the circumstances of the death.

 Secure all necessary signatures on the certificate.

 Review the certificate for completeness and accuracy.

 File the death certificate electronically with the local registrar within ten (10) days of death

[HSC 193.003(a)].

 Use all necessary permits and other forms associated with the death registration process

such as the Burial-Transit Permit and Disinterment Permit.

 Cooperate with the Vital Statistics Section (VSS) and local registrars regarding inquiries

about death certificate entries.

 Call VSS or the local registrar for advice and assistance as needed.

Sometimes, two parties may provide conflicting information regarding the deceased. For example,

the informant may state that the deceased is married (either common-law or by ceremony), but the

family says otherwise (or vice versa). Also, there may be a conflict as to who will be listed as the

surviving spouse. In these cases, the funeral director can ask for documentation or list the

information provided by the informant because he or she is the funeral home customer. The funeral

director has a statutory obligation to file the certificate on time. If necessary, conflicting parties can

resolve their argument through the court system.

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CHAPTER 2

CERTIFYING DEATH

GENERAL INFORMATION

Circumstances of death determine who may certify the cause and manner of death. The certifier is

responsible for verifying the date of death in Item 3 and completing the medical certification

portion of the Texas Certificate of Death, Items 29 - 38. If the death is other than natural, the

Medical Examiner and Justice of the Peace must also complete items 39 - 41. The certifier must

complete the medical certification not later than five (5) days after receiving the death certificate or

provide notification to the funeral director, or person acting as such, explaining the reason for the

delay [HSC 193.005(b)(g)].

Death certificates must be filed within ten (10) days from the date of death. The funeral director

may ask the family for assistance as they are often very effective in expediting the certification

process. If a lengthy investigation is performed, such as an autopsy, the death certificate should be

filed "Pending Investigation.”

The certifier's degree or title should also be indicated.

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 these types of death. A medical examiner should

also be called if a death occurs within 24 hours of admission to a hospital (regardless of the manner

of death). This provision does not apply to justices of the peace.

Upon receipt of autopsy results, or other information that could change the information in the

medical certification on the certificate, the appropriate certifier should immediately amend the

certificate. See Chapter 3 for additional information about filing an Amendment to Medical

Certification of Certificate of Death.

A registered nurse or physician's assistant may pronounce death if the deceased was not on life

support systems and it is permitted under the written policies of the licensed health care facility,

institution, or other entity providing services to that person [HSC 671.001(d)]. However, a

registered nurse or physician's assistant may not certify to the cause and manner of death on the

death certificate. Only a licensed physician, medical examiner, or justice of the peace may sign as

the certifier of cause of death.

Do not confuse pronouncement and certification of death. The individual who pronounces death

may not necessarily be the same person that certifies the death.

If the manner of death is natural, the attending physician should be called immediately. If the

attending physician may be the personal family physician, he or she may be the best source of

information regarding the cause of death in cases where the death is due to natural causes. The

personal physician may have knowledge of pre-existing medical conditions. The personal physician

may certify the death to the best of my knowledge even if he or she did not pronounce the death or

had not seen the patient for some time.

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Sometimes, the attending physician does not know why the person died and/or simply refuses to

certify the death certificate. The certifier should be assured that the cause of death is his or her best

opinion. If additional information becomes available at a later time, a medical amendment can

always be filed at no charge. The funeral director may ask for assistance from the family, local

registrar, or justice of the peace to expedite certification. If all else fails, the funeral director should

call the medical examiner or justice of the peace immediately.

DEATHS CERTIFIED BY THE ATTENDING PHYSICIAN

If the death is by natural causes, the cause of death section of the death certificate should be

completed and signed by the physician that was responsible for the care and treatment of the

condition or disease process that contributed to the death [HSC 193.005(a)]. This physician is

generally the decedent’s primary care physician. He or she is the best source of information

regarding the cause of death in cases where death is due to natural causes. The primary

care physician may certify the death to the best of his or her knowledge even if he or she did not

pronounce the death or had not seen the patient for some time. The primary care physician may

also have knowledge of any pre-existing medical conditions.

If the death occurs under hospice care, the deceased's primary care physician may certify the

death. However, if the decedent was being treated by a hospice physician for an extended period of

time, the hospice doctor should complete the medical certification.

According to the Department of State Health Services Office of General Counsel, an intern who is not

a licensed physician, but was the last physician in attendance at the time of death, may sign a death

certificate for a death that occurred inside or outside the teaching hospital provided the procedure

is within the scope of the hospital's approved training program for the intern.

The physician shall complete the medical certification not later than five (5) days after receiving the

death certificate [HSC 193.005(b)]. An associate physician, the chief medical officer of the

institution where the death occurred, or the physician who performed an autopsy on the deceased

may complete the medical certification if all of the following conditions are met:

 The attending physician is unavailable.

 The attending physician approves.

 The person completing the medical certification has access to the medical history of the

case and the death is due to natural causes [HSC 193.005(c)].

DEATHS CERTIFIED BY THE MEDICAL EXAMINER OR JUSTICE OF THE PEACE

Notify the medical examiner or justice of the peace for an investigation or inquest and cause of

death certification if law enforcement or someone else has not already done so if any of the

following circumstances exist [HSC 193.005, CCP Art. 49.04, CCP Art. 49.25 Sec. 6]:

 A body was found and the cause and circumstances of the death are unknown.

 The death is believed to be an unnatural death from a cause other than a legal execution

(accident, suicide, or homicide).

 The death occurred in prison or in jail.

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  The death occurred within 24 hours of admission to a hospital (refer to a medical examiner 
only CCP Art. 49.25 Sec. 6 (1) ).  
  The death occurred without medical attendance.  
  The physician is unable or unwilling to certify the cause of death.  
  The deceased is under six (6) years of age.  
The person conducting an inquest shall complete the medical certification not later than five (5) 
days after receiving the certificate and submit the record electronically [HSC 193.005]. The disease 
or condition(s) that initiated the events leading to death should be indicated on the medical 
certification. If the death was from external causes, state the means of death and whether the death 
was accident, suicide, or homicide. Complete other information as needed to properly classify the 
death [HSC 193.005(e)].  
DEATHS CERTIFIED BY THE COUNTY JUDGE  
Senate bill 164, signed on May 22, 2001, requires that the county judge be notified regarding a 
death if a justice of the peace is not available to conduct an inquest. The county judge should be 
notified only in cases that require an inquest. Under these circumstances, the county judge now has 
the authority to sign the death certificate as the certifier only if a justice of the peace is still 
unavailable [CCP Art 49.07(C), CCP Art. 49.16].  
DEATH OF A CHILD LESS THAN SIX (6) YEARS OF AGE  
A medical examiner or justice of the peace notified of the death of a child under age six shall hold an 
inquest to determine whether the death was unexpected or the result of abuse or neglect. An 
inquest is not required if the child's death was expected and was due to a congenital or neoplastic 
disease. A death caused by an infectious disease may be considered an expected death if the 
following conditions are met:  
  the disease was not acquired as a result of trauma or poisoning;  
  the infectious organism is identified using standard medical procedures; and  
  the death is not reportable to Texas Department of Health under Chapter 81, Health and 
Safety Code [Family Code(FC) ;264.514(a)].  
Deaths to children less than six (6) years of age are reported to the medical examiner or justice of 
the peace [Family Code (FC) 264.513].  
UNIDENTIFIED PERSONS    
The justice of the peace investigating the death of a person whose body is found, and the cause or 
circumstances of death are unknown, shall report the death to the Missing Children and Missing 
Persons Information Clearinghouse of the Department of Public Safety and the National Crime 
Information Center within ten (10) working days [CCP Art. 49.04(d)]. The report should be made 
even if the body is identified.  
The physician who performs a postmortem examination on the body of an unidentified person shall 
complete and file a death certificate. The physician shall note on the certificate the name of the law 
enforcement agency that submitted the body for examination along with the case number. A copy of 

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the certificate should be sent to the Missing Children and Missing Persons Information

Clearinghouse within ten (10) days of the date the physician files the certificate.

IF REMAINS ARE FOUND

A current death certificate can be only filed within one year of the approximated date of death. If a

current death certificate form is utilized, list "date found" as the date of death. If the death occurred

over one (1) year before the remains were found, a Court-Ordered Delayed Certificate of Death

should be filed.

MISSING OR UNRECOGNIZABLE REMAINS

Before any certificate can be filed, the person must be declared dead by a District Court in Texas.

VSS is not aware of any statute that specifies a time period to wait before having someone declared

legally dead. The District Judge makes the determination based on the evidence presented to the

court. If a court order is obtained, a Court-Ordered Delayed Certificate of Death must be presented

to the County Probate Court Judge in duplicate. The date of death on these types of forms may be

completed to show "Presumed" or "Declared" dead with the date the judge determines to be the

date of death. Once the Court-Ordered Delayed Certificates of Death are signed by the judge, one

copy should be filed with the county clerk and the other copy with State VSS.

CONFIDENTIALITY OF INFORMATION

The fact of death (name, date, place) of an individual is public knowledge; however, the death

certificate is not. A death certificate is a confidential record for the first 25 years after the date of

death and may be released only to a properly qualified applicant [HSC 191.051; GC 552.115].

PENALTIES

It is a Class A misdemeanor for a person to knowingly reveal or induce another to reveal

confidential information from a death or fetal death certificate. It is a Class C misdemeanor for a

person to refuse or fail to furnish any information in the person's possession affecting a death

certificate. It is also a Class C misdemeanor for a person to fail, neglect, or refuse to fill out and file a

death, or fetal death certificate, with the local registrar or deliver the certificate upon request to the

person with the duty to file it. It is a third degree felony to falsely obtain, use, or alter a certificate of

death with a fine of up to $10,000 and 2-10 years in prison [HSC §195.005].

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INSTRUCTIONS FOR COMPLETING A CERTIFICATE OF DEATH

GENERAL INSTRUCTIONS FOR DEATH CERTIFICATES

Complete only one Certificate of Death and file it with the appropriate local registrar. Entering a

duplicate record for correction into Texas Electronic Death Registration is not acceptable. Texas

Electronic Death Registration will print the death certificate with the most current form, VS-112

(Revised 1/2006), designated by the Texas Department of Health, Vital Statistics Section (VSS).

The death certificate must be filed electronically, as specified by the state registrar, 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]. In Addition the person completing the medical

certification shall submit the information and attest to its validity using by electronic process

specified by the state registrar.[HSC 193.005(h)]. This electronic processes is Texas Electronic

Death Registration

Complete each item following the specific instructions for that item. Do not leave a space blank

unless specifically instructed to do so. If the record has been dropped to paper, avoid using

correction fluid, make alterations, erasures, or strike-overs. Obvious changes affect the validity of a

certificate. Altered certificates may be rejected by the local registrar or VSS [HSC 191.027, HSC

191.031] Avoid abbreviations except for those suggested in the item-by-item specific instructions.

Verify the spelling of all names and numbers with the informant.

Detailed instructions for certifying the cause of death may be found in the Handbook on Medical

Certification of Cause and Manner of Death. Refer problems not covered in these instructions to VSS

or your local registrar .

DEATH CERTIFICATE PAPER SPECIFICATIONS

There must be at least a 3/4 inch margin from the top of the paper to the top line of the form. This

margin is required for VSS to record the state file number on the death certificate.

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CHAPTER THREE

AMENDING THE CERTIFICATE OF DEATH

INTRODUCTION

Once a record has been filed by the local registrar and forwarded to the Vital Statistics Section (VSS)

it may only be corrected by the amendment process. An original record or entry cannot be altered

[HSC 191.028]. The amendment form becomes an addendum to the original record.

The $15.00 fee for filing an amendment is separate from the $22.00 fee for certified copies.

Additional copies of the same death certificate are $3.00 each.

A copy of the completed amendment to the Certificate of Death will be forwarded to the local

registrar and/or county clerk of the registration district where the death originally occurred.

The Application for Amendment to Certificate of Death (VS-172) (60K .pdf) may be used to request

completion of any item left blank on the original record or to correct any errors made during the

completion of the original record, except information relating to medical certification to cause and

manner of death and the date of death which requires an Amendment to Medical Certification of

Certificate of Death (VS-174).

PROCEDURES FOR AMENDING CERTIFICATE OF DEATH

A properly completed Application for Amendment to Certificate of Death (VS-172) (60K .pdf) must

be submitted to the State Registrar with the required fee.

THE FORM VS-172 SHOULD BE USED TO COMPLETE OR CORRECT ONLY THE NON-MEDICAL

PORTION OF THE CERTIFICATE OF DEATH.

A Certificate of Death may only be corrected with an application submitted by the informant,

funeral director, immediate next-of-kin, or court of competent jurisdiction.

ONLY THE ORIGINAL INFORMANT MAY AMEND THE MARITAL STATUS OF THE DECEASED. If the

informant is unable or unwilling to request this change, a court of competent jurisdiction may make

the determination of the marital status of the deceased in the following situations:

 a party claims he or she is the surviving spouse and is not listed as such,

 two, or more parties claim to be the surviving spouse, or

 the record shows the deceased to have been divorced, never married, or widowed and no

surviving spouse is listed, and a party is claiming to be the surviving spouse.

PART III must be completed and signed before a notary public.

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Parts I, II, and III must be properly completed and submitted to VSS with documentation as

required. A list of documents acceptable for submission in support of an amendment or correction

to a Certificate of Death can be found on the reverse side of the application.

PART I

Enter all information exactly as shown on the original death record. Item 3 should show the city and

county of death; Item 5 should show the state file number if known; if not, leave blank.

PART II

Enter the item name and number to be changed in block 8. Enter the incorrect or wrong

information in block 9 as shown on the original certificate. Enter the correct information in block

10. Be very careful of spelling, etc. in block 10. This will be the new correct information entered on

the record.

PART III

This section must be signed before a notary public. A person who was acquainted with the facts at

the time the death occurred, preferably by the informant, physician, or funeral director that signed

the original certificate should sign this affidavit.

DOCUMENTATION

Any significant or major change in the name of the deceased or the names relating to parents shown

on the original record will require documentation. Generally, the affidavit and one acceptable

document are sufficient. Part V on the back of the Application to Amend Certificate of Death

provides examples of corrections and the types of documents required.

FILING MEDICAL AMENDMENTS

To correct information on the medical portion of the death certificate (Items 3, and 30-41f), or to

report the cause and manner of death for a certificate that was filed "Pending Investigation," an

Amendment to Medical Certification of Certificate of Death (VS-174) must be completed through

the Texas Electronic Death Registration System. A medical amendment must be filed to change the

cause and manner of death. No changes or additions may be made on the face of an original record

[HSC 191.028].

A medical amendment may be filed any time after the original death certificate has been filed with

the local registrar. The amendment may be completed and submitted only by the attending

physician, justice of the peace office, or medical examiner's office, that originally certified the death.

There is one exception to this rule: if an inquest was conducted by a medical examiner of justice of

the peace, the person conducting the inquest may sign the medical amendment if the death was

originally certified by a physician.

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If the original certifier is unable or unwilling to sign the Amendment to Medical Certification of

Certificate of Death, a court order from a court of competent jurisdiction is required to file the

amendment.

There is no fee authorized to file an Amendment to Medical Certification of Certificate of Death.

INSTRUCTIONS FOR COMPLETING A MEDICAL AMENDMENT IN TXEVER

MEDICAL AMENDMENT CREATION PROCESS

1. The Medical Certifier or Staff Member searches for and retrieves the record. The record will

be locked at this point.

2. The Medical Certifier or Staff Member clicks on the Medical Amendment Icon.

3. The user will then be prompted with the message, “Are you sure you want to add a Medical

Amendment to this record?”

4. The Medical Certifier or Staff Member clicks on the “Yes” button to continue with the

medical amendment.

5. The record will then be unlocked so the user can make the desired changes.

6. The Medical Certifier or Staff Member saves the amendment. Once the medical amendment

was successfully saved, the user will be prompted with the message, “The medical

amendment request was saved successfully.”

7. The amendment will then go into the Medical Amendment Review Queue to be reviewed

and approved by the Medical Certifier. See Medical Amendment Review Process for step by

step instructions on how to complete this process

MEDICAL AMENDMENT REVIEW PROCESS

1. The Medical Certifier searches for and retrieves the record.

2. The Medical Certifier clicks on the Review Medical Amendments icon.

3. The Medical Certifier enters their pin.

4. The Medical Certifier reviews the pending medical amendments then selects either the

Accept or Reject icons. Rejecting the amendments will permanently remove all of the

pending amendments for the record.

5. Once the medical amendment is successfully accepted, the user will be prompted with the

message, “The medical amendment request was successfully accepted.”

PLEASE NOTE: CHANGES WILL NOT BE SEEN IN TXEVER AND YOU WILL NOT BE ABLE PRINT A NEW

MEDICAL ABSTRACT WITH THE AMENDED INFORMATION UNTIL VSS PRINTS AND OFFICIALLY FILES

THE MEDICAL AMENDMENT. THIS PROCESS CAN TAKE AT LEAST 2 BUSINESS DAYS AFTER THE

MEDICAL AMENDMENT REVIEW PROCESS IS COMPLETE.

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AUTHORIZATIONS

REPORT OF DEATH FORM (VS-115)

The funeral director or person acting as such, who first assumes custody of a dead body or fetus,

shall within 24 hours either mail or otherwise transmit a Report of Death to the local registrar of

the district in which the death occurred or the body was found. [25 TAC 181.2 (a)]

A copy of the Report of Death form shall serve as authority to transport or bury the body within

Texas. The report of death can be printed from the TxEVER system once the record has been

entered.

BURIAL-TRANSIT PERMIT (VS-116)

A Burial-Transit Permit is required to ship or transport a body out of the state or to transport a

body by common carrier within the state. A Burial-Transit Permit is also required for cremation.

[HSC 193.008, 25 TAC 181.2, 181.3]

If an inquest is conducted by the medical examiner or justice of the peace, authorization for

cremation from the medical examiner or justice of the peace is required in addition to the Burial-

Transit Permit.

A Burial-Transit Permit is not necessary if transporting the body within the state by means other

than common carrier. A copy of the Report of Death form is sufficient.

The local registrar, the deputy registrar, or some other authorized officer of the district in which the

death occurred, or the district in which the body was found issues the Burial-Transit Permit. The

local registrar shall not issue a Burial-Transit Permit until the Certificate of Death, completed in so

far as possible, has been presented.

"Completed in so far as possible" means all of the information relating to the deceased, such as the

name, date of death, place of death, and funeral director's information is complete. In a few

instances, the physician may not have certified the cause of death before removal from the district.

The Texas Health and Safety Code 191.022(c), states that each local registrar must appoint a deputy

registrar so that a registrar is available at all times for the registration of vital records. The funeral

director should look for any notices posted outside the office regarding an alternate for vital

registration for his or her area. This may also include a message on his or her telephone answering

machine.

It is the responsibility of the funeral director filing the Certificate of Death completed as far as

possible, and obtaining the Burial-Transit Permit, to assure that the fully completed Certificate of

Death is filed with the local registrar as soon as possible. If an incomplete certificate is used to

obtain the Burial-Transit Permit, the registrar may wish to confirm that the body is no longer

needed by the certifier before issuing the permit. This helps assure that a completed death

certificate will be received.

A Burial-Transit Permit, properly issued under the law and rules of a place outside this state in

which the death occurred, also authorizes the transportation of the body in this state. A cemetery or

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crematory shall accept the permit as authorization for burial, cremation, or other disposal of the

body in this state. [HSC 193.008 (a)]

If a body is buried, then later disinterred and taken out of this state, the funeral director must

obtain a Burial-Transit Permit from the local registrar in the district in where the death occurred in

addition to a Disinterment Permit.

There is no fee authorized for the issuance of a Burial-Transit Permit. Please contact the local

registrar for information on how to obtain a Burial-Transit Permit during non-business hours

and/or holidays.

TRANSPORTING A BODY TO A FOREIGN COUNTRY

MEXICO

To ship a body from Texas to Mexico a Burial-Transit Permit, a certified copy of the Texas

Certificate of Death and an Apostille from the Texas Secretary of State's Office is generally required.

In addition, the funeral director or person acting as such may need to have the death certificate and

Apostille translated into Spanish. Then the body may be shipped to Mexico in accordance with

specific local custom at the point of entry.

A Burial-Transit Permit, required to remove a body from this state, must be obtained from the local

registration office of the district in which the death occurred. In addition, a certified copy of the

Texas Certificate of Death may also be obtained from the local registration office of the district in

which the death occurred.

The purpose of an Apostille is to authenticate a document so that it will be accepted in a foreign

country. The Secretary of State has the authority to prepare an Apostille for any document created

within the state's jurisdiction, including a Texas Certificate of Death.

Please contact the Texas Secretary of State's office form more information regarding Apostille:

Secretary of State

Statutory Document Section

P. O. Box 12887

Austin, Texas 78701

COUNTRIES OTHER THAN MEXICO

To ship a body from Texas to a country other than Mexico, check with the consulate of that country

for specific requirements. If the body is removed from Texas, a Burial-Transit Permit must be

obtained.

AUTHORIZATION FOR CREMATION

The Report of Death does not take the place of the Burial-Transit Permit for cremation. A Burial-

Transit Permit must be obtained for cremation. [CCP Art. 49.09, CCP Art. 49.25(10), 25 TAC 181.2]

A body may not be cremated until 48 hours after death as indicated on the Certificate of Death

unless the death certificate indicates the death was due to Asiatic cholera, bubonic plague, typhus

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fever, or small pox. The time requirement may also be waived in writing by the medical examiner or

justice of the peace.

If an inquest is conducted by the medical examiner or justice of the peace, authorization for

cremation from medical examiner or justice of the peace is required in addition to a Burial-Transit

Permit. The body may not be cremated until the medical examiner or justice of the peace has signed

a certificate stating that an autopsy was performed or that no autopsy was necessary.

DISINTERMENT PERMIT (VS-2219)

The Disinterment Permit issued by VSS serves as the authority to disinter, transport, and reinter a

body within this state. If the body is to be removed from the state, transported by common carrier

within the state, or cremated, a Burial-Transit Permit must also be obtained. [HSC 694.001, HSC

711.004, 25 TAC 181.6]

A Disinterment Permit shall not be required if a body is to be disinterred and reinterred in the same

cemetery.

The Application for a Disinterment Permit (VS-271) (39K .doc), must be signed by the funeral

director or embalmer licensed by the Texas Funeral Commission making application for the permit.

The sole responsibility for obtaining the consent of the cemetery, the owner of the plot, and the

deceased's next-of-kin rests with the funeral director or embalmer making application for a

Disinterment Permit. The application, consent forms, and $25.00 required fee must be sent to VSS.

The State Registrar issues the Disinterment Permit in four parts. The funeral director to whom the

permit is issued shall retain a copy, a copy is to be filed by the sexton of the cemetery in which the

reinterment is to be made, a copy shall be filed by the local registrar with the local registrar's copy

of the Certificate of Death, and a copy will be filed by the State Registrar with the original Certificate

of Death.

A Disinterment Permit is good for one (1) year from the date of issuance.

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INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR A DISINTERMENT PERMIT (VS-

271)

Please type or print except where signatures are required. Names may be typed beneath the

signature for clarification.

1. Enter the full name of the deceased as it appears on the Certificate of Death.

2. Enter the exact date of death. This information is vital in locating and identifying the

Certificate of Death.

3. Enter the city, county, and state of death.

4. Enter the place of interment. These items must be completed with the full name of the

cemetery, plot number (section, block, lot, and space or niche), city, county, and state in

which the deceased is buried. The state should always be Texas, as we cannot issue a

Disinterment Permit for an out of state burial.

5. Enter the place the body is to be reinterred (Items a-d). These items must be completed

with the full name of the cemetery, plot number (section, block, lot, and space or niche), city,

county, and state where the body will be reburied.

6. Enter the funeral director's full name and state license number along with the full name,

address, and telephone number of the funeral home.

7. Provide the date and signature of the funeral director submitting the application.

Please type or print except where signatures are required. Names may be typed beneath the

signature for clarification.

INSTRUCTIONS FOR COMPLETING THE DISINTERMENT CONSENT FORM (VS-271.1)

Procedures for Completing the Cemetery Consent Form

The first portion of the Cemetery Consent Form must be completed by the cemetery owner or

keeper.

 Enter the full name of the deceased as it appears on the Certificate of Death.

 Enter the plot and block number where the body is buried.

 Enter the full name of the plot owner(s).

 The signature line should be completed by the cemetery owner or keeper.

 Enter the date the form was signed.

 Enter the title of the person signing for the cemetery.

 Enter the full name of the cemetery where the body is buried.

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PROCEDURES FOR COMPLETING THE PLOT OWNER CONSENT FORM

The middle portion of the Plot Owner Consent Form should be completed by the owner of the plot

where the body is buried.

 Enter the plot and block number where the body is buried.

 Enter the complete name of the cemetery where the body is buried.

 Enter the full name of the deceased as it appears on the Certificate of Death.

 The signature line should be completed by the owner of the plot.

 Enter the date signed, along with the address and telephone number of the plot owner.

NEXT-OF-KIN

The third portion of the form entitled Next-of-kin Consent Form must be completed by the next-of-

kin in order of priority [HSC 711.004 (a)]:

 the decedent's surviving spouse;

 the decedent's surviving adult children;

 the decedent's surviving parents;

 the decedent's adult siblings; or

 the adult person in the next degree of kinship in the order named by law to inherit the

estate of the decedent.

Please Note: A person listed above may consent to the removal only if there is no person in a

priority listed before that person. [HSC 711.004(b)]

PROCEDURES FOR COMPLETING THE NEXT-OF-KIN CONSENT FORM:

 Enter the relationship of the signer to the deceased.

 Enter the full name of the deceased as it appears on the Certificate of Death.

 Enter the full name of the cemetery where the body is to be reburied.

 The signature line should be completed by the next-of-kin.

 Enter the date signed.

If all the required consent signatures cannot be obtained, the remains may be removed by

permission of the county court of the county in which the cemetery is located. [HSC 711.004 (c)]

DELAYED REGISTRATION OF DEATH

OVERVIEW

If a death is registered with the Vital Statistics Section (VSS), but is not recorded locally, VSS may

furnish the local registrar, upon request, a plain copy of the original record for recording in his or

her office.

If a death record over one (1) year old is recorded in the office of a local registrar, but not with the

VSS, the Attorney General of Texas in Opinion No. 0-3775 (September 5, 1941) advised the State

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Registrar that he or she is not authorized to accept for filing either the original certificate in the

office of the local registrar or a certificate made from it.

The statutes that govern registration by judicial order (deaths) can be found in the Texas Health &

Safety Code 193.007.

DEATH REGISTRATION BY JUDICIAL ORDER

A delayed death certificate may be filed only by the county probate court in the county in which the

death occurred for individuals who died in Texas but did not have a death certificate filed within

one (1) year from the date of death.

The Court-Ordered Delayed Certificate of Death (VS-128) must be supported by the following

affidavit(s):

Affidavit A must be signed by either the:

 Physician last in attendance,

 Funeral director in charge of disposition, or person acting as such, or

 Any person who signs Affidavit A must also be listed as the informant in Item 21 and enter

his or her address in Item 22 and obtain his or her signature in Item 23.

Affidavit B must also be signed when:

 Affidavit A is signed by someone other than last physician in attendance or the funeral

director in charge of disposition. In these cases, Affidavit B is signed by a person acquainted

with the death facts, but not related to the deceased by blood or marriage.

The certificate must be presented in duplicate to the county probate court of the Texas County in

which the death occurred. Once completed and signed by the judge, one original is forwarded to

VSS and the other original is filed by the county clerk. All items must be completed. If the

information is not known, enter the word "Unknown." The county probate court may require

additional supporting documents.

VSS is not authorized to accept a delayed death record if the text of the affidavits of the standard

form has been changed in any respect or if any supplemental documents are attached to the

standard form.

If a delayed death record is found to be in error, application for correction of the record must be

made to the probate court approving the original registration. Upon receipt of satisfactory evidence

supporting the requested correction, the probate court will prepare an Amendment to Delayed

Certificate of Death (VS-124.1) which will be forwarded to VSS Request Processing who will attach

it to the original record. A copy of the amendment will also be filed behind the record filed in the

office of the county clerk.

If it is necessary to amend a Delayed Certificate of Death approved by a probate court, contact the

VSS Supply Representative and request the Amendment to Delayed Certificate of Death (VS-124.1).

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CHAPTER FOUR

ITEM-BY-ITEM INSTRUCTIONS

1. LEGAL NAME OF DECEDENT (INCLUDE AKAS IF ANY) (FIRST, MIDDLE, LAST):

Enter the full legal first, middle, and last name of the decedent. Enter the maiden name for women.

Do not abbreviate a name. If there appears to be more than one spelling of any name provided and

the correct spelling cannot be verified, use the most common spelling. The name must consist of

English alphabetic characters and punctuation marks. If the informant indicates two first names

separated by a space, such as ‘‘Mary Louise Carter,’’ verify that ‘‘Louise’’ is part of the first name and

is not a middle name. Enter the two first names with the middle name blank. If several middle

names are given, enter all with a space between the names.

 If the decedent's identity is not known, enter "John Doe" or "Jane Doe", as appropriate and

an investigation case number.

 If there is a title preceding the name, such as ‘‘Doctor,’’ do not enter the title in any of the

name fields.

 For religious names such as ‘‘Sister Mary Lawrence,’’ enter ‘‘Sister Mary’’ in the first name

field.

 If the decedent was an infant and no first name is provided, enter "Infant."

Initials:

 If the informant indicates that the person uses a first initial such as ‘‘E. Charles Jones,’’ try to

obtain the whole first name.

 If the name can be obtained, enter the whole first name. If not, enter just the initial followed

by a period.

 If the informant indicates two initials and a surname such as ‘‘H.S. Green,’’ determine if

these are a first and middle initial, or two first initials with no middle name or initial. Try to

obtain the whole name(s).

 If the names can be obtained, enter the whole names in the appropriate spaces. If there are

no whole names, enter the initials in the appropriate spaces. Each initial should be followed

by one period.

Aliases: An alias or "A.K.A." should be entered into the AKA section in Texas Electronic Death

Registration by selecting the Add button. Complete the current legal name before entering any

other names (alias or AKA, ‘‘also known as,’’ names such as AKA John Smith) the decedent used or

was known as. The alias should be listed if it is substantially different from the decedent’s legal

name (e.g., Samuel Langhorne Clemens AKA Mark Twain, but not Jonathon Doe AKA John Doe).

Repeat until there are no other names provided.

AKA does not include:

 Nicknames, unless used for legal purposes or at the family’s request.

 Spelling variations of the first name.

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 Presence or absence of middle initial.

 Presence or absence of punctuation marks or spaces.

 Variations in spelling of common elements of the surname, such as "Mc" and "Mac" or "St."

and "Saint."

This item is used to identify the decedent. This is the most important item on the certificate for legal

and personal use by the family. There are alternate spellings to many names, and it is critical for the

family to have the name spelled correctly.

2. DATE OF DEATH:

Enter the exact date, in standard order of “month, day, year”, that the death occurred. Enter the in

an 8 digit numerical value ( mm/dd/yyyy exp. 01/15/2012) when using TxEVER. If you are

completing a paper record, you must spell out the name of the month when entering the date (exp.

January 15, 2012)

Consider a death at midnight to have occurred at the end of one day rather than the beginning of

the next. The date for a death that occurs at midnight between December 31 and January 1 should

be recorded as December 31.

Date of Death Type: For the TxEVER Program select one of the following options;

 Actual - The definitive Date of death according to available information.

 Presumed - The assumed date of death when the actual date is unknown due to missing

information or a missing person;

 Estimated - The exact date of death is not known but can be approximated based on

documentation; and

 Found - The time at which remains were discovered. [This is usually when a body has been

found after a very extended period of time and time of death cannot be estimated or

presumed.

Presumed, Estimated, and Found are primarily used by Justices of the Peace and Medical

Examiners.

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3. SEX:

Select male or female based on observation. Do not abbreviate or use other symbols. If sex cannot

be determined after verification with medical records, inspection of the body, or other sources,

select Unknown. Do not leave this item blank.

This item aids in the identification of the decedent. It is also used in research and statistical analysis to

determine sex-specific death rates.

4. DATE OF BIRTH:

Enter the month, day, and year that the decedent was born. If no information is available, enter one

question mark (?).

5. AGE:

Enter the decedent's exact age in years at his or her last birthday. If the exact date is not known,

enter one question mark (?).

If the decedent was under one year of age:

 Enter the age at the time of death in either completed months or days in the appropriate

space.

 If the infant was 1-11 months inclusive, enter the age in completed months.

 If the infant was 28 days old, enter one month.

 If the infant was less than 28 days old, enter the age in completed days.

If under 1 day: For infants who did not survive for an entire day, enter the exact number of in

completed hours or minutes the infant lived in the appropriate block. (Exp. Decedent lived 3 and 17

minutes you would enter 3 hours)

 If the infant lived 1-23 hours inclusive, enter the age in completed hours.

 If the infant was less than 1 hour old, enter the age in minutes.

 If the infant lived only a few seconds, enter one minute.

If Age does not agree with the date of birth and the date of death a hard-check alert will appear

forcing you to correct one of the 3 items so that they correspond with each other.

If the body is found and the exact date of death is not known, enter the age the person would have

been on the date he or she was found.

6. BIRTHPLACE (CITY & STATE OR FOREIGN COUNTRY):

If the decedent was born in the United States, enter the name of the city and state. This item is used

to match birth and death certificates of the decedent in their birth state. Matching these records is

required by law to prevent the use of birth certificates of the decedent for fraudulent purposes.

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 If the decedent was born in the United States, but the city is not known, enter the name of

the state only and Unknown in the City of Birth Field. If the state is not known, select United

States for the State/Foreign Country section and enter Unknown for the city of birth.

 If the decedent was born in a foreign country, enter the name of the country of birth in the

State/Foreign Country section and the name of the foreign city in the City field.

 If the decedent was born in a foreign country but the city of birth is not known, enter the

name of the country of birth in the State/Foreign Country section and Unknown in the city

section.

 If the decedent was born in a foreign country but the country is unknown, enter Unknown

in State/Foreign County section and Unknown in the city section.

 If no information is available regarding the place of birth, enter Unknown in both sections.

This item is used to match birth and death certificates of a decedent individual. Matching birth and

death records provides information from the birth certificate that is not contained on the death

certificate and may give insight into which conditions led to death. Information from the birth

certificate is especially important in examining the causes of infant mortality.

7. SOCIAL SECURITY NUMBER:

Enter the social security number (SSN) of the decedent. Do not leave this item blank. All social

security numbers are exactly nine (9) digits (XXX-XX-XXXX). Special attention should be given to

entering the correct social security number. TxEVER will make you re-enter the SSN to insure the

intended number was entered.

If the decedent did not have a social security number (such as resident aliens or newborns), enter

one question mark (?). This will mean unknown or not available.

8. MARITAL STATUS:

Select the marital status of the decedent at the time of death. Select only one of the following:

Married, Never Married, Widowed, Divorced, or Unknown. Common law marriage is legal in Texas,

but both parties must be at least 18 years old. A person is legally married even if separated. A

person is no longer legally married only after a divorce has been granted by a judge or after the

death of the spouse.

‘‘Annulled and not remarried’’ and ‘‘never previously married’’ are considered Never Married.

‘‘Married previously’’ is classified as how the previous marriage terminated (Widowed or

Divorced).

If a married couple is killed at the exact same time, Married should be selected on each death

certificate and Surviving Spouse should be completed with the name of the spouse. This situation

may occur in an automobile accident.

If the medical examiner or justice of the peace can determine different times of death, these items

would be completed according to the time of death. The first to die would be listed as "Married" and

the second as "Widowed."

This information is used in determining differences in mortality by marital status.

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9. SURVIVING SPOUSE (IF WIFE, GIVE NAME PRIOR TO FIRST MARRIAGE):

If the decedent was married at the time of death, enter the full name of the surviving spouse.

If the surviving spouse is the wife, enter her name prior to first marriage (i.e., maiden name).

This item is used in genealogical studies and in establishing proper insurance settlement and other

survivor benefits.

10. RESIDENCE:

The residence of the decedent (State, county, city, and street address) is the place where his or her

household is located, the place where the decedent actually resided, or where the person lives and

sleeps most of the time. This is not necessarily the same as the home State, voting residence,

mailing address, or legal residence.

Do not enter addresses that are post office boxes or rural route numbers. Get the building number

and street name for the residence address rather than the postal address.

Temporary residence: Never enter a temporary residence, such as one used during a visit, business

trip, or a vacation. However, usual onshore place of residence during a tour of military duty is not

considered temporary and should be entered as the place of residence on the certificate. Similarly,

usual place of residence during attendance at college is not considered temporary and should be

entered as the place of residence on the certificate.

Multiple residences: If the decedent lived in more than one residence (parent living in a child’s

household, children in joint custody, person owning more than one residence, or commuters living

elsewhere while working), enter the residence lived in most of the year. If a child lives an equal

amount of time in each residence, report the residence where the child was staying when death

occurred.

Institutions or Group Homes: If a decedent had been living in a facility where an individual usually

resides for a long period of time, such as a group home, mental institution, nursing home,

penitentiary, or hospital for the chronically ill, long-term care facility, congregate care facility, foster

home, or board and care home, this facility should be entered.

Children: If the decedent was a child, residence is the same as that of the parent(s), legal guardian,

or custodian unless the child was living in an institution where individuals usually reside for long

periods of time, as indicated above. In those instances, the residence of the child is shown as the

facility. Children residing at a boarding school are considered to live at a parent’s residence.

Residence for foster children is the place they live most of the time.

Infant: If the decedent was an infant who never resided at home, the place of residence is that of the

mother or legal guardian. Do not use an acute care hospital as the place of residence for any infant.

RESIDENCE STREET ADDRESS [10A]

Enter the number assigned to the decedent’s residence (e. g. 1100). If the street name has a

direction as a prefix, enter the prefix in front of the street name (e.g., South Main Street). If the

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street name has a direction after the name, enter the direction after the name (e.g., Florida Avenue,

NW). Report the street designator (e.g., Street, Road, Avenue, or Court). If the number and/or name

are unknown, enter Unknown.

APT. NO. [10B]

Enter the apartment or room number associated with the residence. If there is no apartment or

room number associated with this residence, leave the item blank.

CITY OR TOWN [10C]

Enter the name of the city, town, or location in which the decedent lived. This may differ from the

city, town, or location used in the mailing address.

If outside the city limits, enter the justice of the peace precinct number or city and precinct number.

To complete this in TxEVER:

 Select (Add New Town) from the bottom of the City/Town menu.

 When the AOF Screen appears, enter the precinct number or city and precinct number:

(exp: Precinct 1 or Caldwell Precinct 1)

 Select Ok and the information will populate in the City/Town field

COUNTY [10D]

Enter the name of the county in which the decedent lived. If the decedent resided in any country

other than the United States and its territories, leave this item blank.

STATE [10E]

Enter the name of the State in which the decedent lived. This may differ from the State in the

mailing address. If the decedent was not a resident of the United States, enter the name of the

country and the name of the unit of government that is the nearest equivalent to a State.

 This item is where the U.S. States and territories and the provinces of Canada are recorded.

 If the decedent lived in a Canadian province or territory, enter the name of the province or

territory. If resident of any other country, enter the name of the country in the space for

State.

 If the decedent’s residence is unknown, enter Unknown.

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ZIP CODE [10F]

Enter the ZIP Code of the place where the decedent lived. This may differ from the ZIP Code used in

the mailing address. The 9-digit ZIP Code is preferred over the 5-digit ZIP Code. If only the 5-digit

ZIP Code is known, report that. If the decedent was not a resident of the U.S. or its territories, leave

this item blank..

INSIDE CITY LIMITS [10G]

Select Yes if the location entered in 10c is incorporated and if the decedent’s residence is inside its

boundaries. Otherwise enter No. If it is not known if the residence is inside the city or town limits,

select Unknown in the space.

Mortality data by residence are used with population data to compute death rates for detailed

geographic areas. These data are important in environmental studies. Data on deaths by place of

residence of the decedent are also used to prepare population estimates and projections. Local officials

use this information to evaluate the availability and use of services in their area. Information on

residence inside city limits is used to properly assign events within a county. Information on ZIP Code

and whether the decedent lived inside city limits is valuable for studies of deaths for small areas.

11. FATHER'S NAME:

Enter the first, middle, and last name of the father of the decedent.

 If there appears to be more than one spelling of any name provided, and the correct spelling

cannot be verified, use the most common spelling.

 The name must consist of English alphabetic characters.

 If no information is available regarding the father's name, leave the first and middle name

blank and enter Unknown in the last name field.

12. MOTHER'S MAIDEN NAME:

Enter the name (first, middle, and surname) the mother of the decedent used prior to first marriage,

commonly known as the maiden name. This is the name given at birth or adoption, not a name

acquired by marriage. This name is useful because it remains constant throughout life.

 If no information is available regarding the mother's maiden name, eave the first and

middle name blank and enter Unknown in the last name field.

The names of the decedent’s mother and father aid in identification of the decedent’s record. The

mother’s name prior to first marriage or maiden surname is important for matching the record with

other records because it remains constant throughout a lifetime in contrast to other names that may

change because of marriage or divorce. These items are also of importance in genealogical studies.

13. PLACE OF DEATH (CHECK ONLY ONE):

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The place where death is pronounced should be considered the place where death occurred. If the

place of death is unknown but the body is found in your State, the certificate of death should be

completed and filed in accordance with the laws of your State. Enter the type of place where the

decedent was pronounced dead.

HOSPITAL DEATHS:

If the decedent was pronounced dead in a hospital, enter the decedent’s status at the Hospital:

Inpatient, Emergency Room/Outpatient (ER), or Dead on Arrival (DOA). Hospitals are licensed

institutions providing diagnostic and therapeutic services to patients by a medical staff.

NON-HOSPITAL DEATHS:

If the decedent was pronounced dead somewhere else, enter whether pronouncement occurred at a

Hospice facility, Nursing home/Long term care facility, Decedent’s home, or other location.

Hospice facility refers to a licensed institution providing hospice care (e.g., palliative and supportive

care for the dying), not to hospice care that might be provided in a number of different settings

including a patient’s home.

If death was pronounced at a licensed long-term care facility, enter Nursing home/Long term care

facility. A long-term care facility is not a hospital but provides patient care beyond custodial care

(e.g., nursing home, skilled nursing facility, long-term care facility, convalescent care facility,

extended care facility, intermediate care facility, residential care facility, and congregate care

facility).

If death was pronounced in the decedent’s home, enter Decedent’s home. A decedent’s home

includes independent living units including private homes, apartments, bungalows, and cottages. If

death was pronounced at a licensed ambulatory/surgical center, orphanage, prison ward, public

building, birthing center, or facilities offering housing and custodial care but not patient care (e.g.,

board and care home, group home, custodial care facility, foster home), enter Other (Specify). If

Other (Specify) is entered, specify where death was legally pronounced, such as prison ward,

physician’s office, the highway where a traffic accident occurred, a vessel, orphanage, group home,

or at work.

If the place of death is unknown but the body was found in a State, enter the place where the body

was found as the place of death.

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14. COUNTY OF DEATH:

Enter the name of the county where the death occurred.

 If the death occurred in an ambulance which crossed county lines while en-route to a

hospital, enter the place of death as the county where the body was first removed from the

ambulance.

 If the death occurred in a moving vehicle in the United States and the body was first

removed in Texas, complete a Texas Certificate of Death and enter as the place of death the

address where the body was first removed from the vehicle.

 If the death occurred in a moving conveyance in international waters, international

airspace, or in a foreign country or its airspace, and the body was first removed in Texas,

enter the county where the body was first removed from the conveyance (refer to the

information provided in Item 16).

Information on place of death is needed to determine who has jurisdiction for deaths that legally

require investigation by a medical examiner or coroner. These items are also used for research and

statistics comparing hospital and non-hospital deaths. Valuable information is provided for health

planning and research on the utilization of health facilities.

15. CITY OR TOWN, ZIP (IF OUTSIDE CITY LIMITS, GIVE PRECINCT NO.)

Enter the name of the city, town, or village the death occurred and the Zip Code.

If outside the city limits, enter the justice of the peace precinct number or city and precinct number.

To complete this in TxEVER:

 Select (Add New Town) from the bottom of the City/Town menu.

 When the AOF Screen appears, enter the precinct number or city and precinct number: (exp.

Precinct 1 or Caldwell Precinct 1)

 Select Ok and the information will populate in the City/Town field

If the death occurred in a moving conveyance in international waters, international airspace, or in a

foreign country or its airspace, and the body was first removed in Texas, enter the city where the

body was first removed from the conveyance.

16. FACILITY NAME (IF NOT INSTITUTION, GIVE STREET ADDRESS):

If the death occurred in a hospital or a long-term care facility, enter the full name of the institution.

If death did not occur in an institution, give the street address of the place of death.

 If death occurred en route to or on arrival at a hospital, enter the full name of the hospital.

Deaths that occur in an ambulance or emergency vehicle en route to a hospital fall in this

category.

 If the death occurred at home, enter the house number and street name.

 If the death occurred at home and there is no house number or street name, describe the

location; for example, "Hwy. 30, 2 mile east FM 29." Be specific. Do not enter a rural route

and box number.

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 If the death occurred at a place other than described above, enter the number and street

name of the place or describe the location; for example, "Hwy. 30, 2 mile east of FM 29." Be

specific. Do not enter a rural route and box number.

 For a death occurring either at sea or in flight, show the name of the vessel or flight and the

latitude or longitude where the event occurred; for example, "SSA Everett Hill at sea 29d

18m N 94d 48m W" or "Global Airlines Flight 263 in flight 30d 18m N 97d 42m W." It is also

important that the certificate contain some citation of the page and volume number of the

craft's log.

17. INFORMANT'S NAME & RELATIONSHIP TO DECEDENT

Enter the name of the person who supplied the personal facts about the decedent and his or her

family. The informant is usually a member of the family or close family friend.

Enter the relationship of the person supplying the personal information about the decedent. (For

example, this may be a husband, wife, parent, son, daughter, brother, sister, or friend.)

The signature of the informant is not needed. The signatures that are mandatory for filing are those

of the medical certifier, the funeral director or person acting as such, and the local registrar.

At times, the funeral director may be the informant and have to obtain personal information from a

physician, a hospital official, or medical records. In some cases, information will be obtained from

the police. "Funeral Home records" or "Inquest Records" may be the informant when an individual

is not available.

18. MAILING ADDRESS OF INFORMANT (STREET AND NUMBER, CITY, STATE,

AND ZIP CODE)

Enter the complete mailing address of the informant whose name appears in Item 17. Be sure to

include ZIP code.

The name and mailing address of the informant are used to contact the informant when inquiries must

be made to correct or complete any items on a death certificate.

19. METHOD OF DISPOSITION

Only one box should be selected.

Check the box corresponding to the method of disposition of the decedent's body.

If the decedent is being cremated then entombed or buried, Cremation should be selected

"Removal from State" should be indicated when the body is being removed or shipped out of Texas

for burial or other disposition.

If the body is to be used by a hospital, medical, or mortuary school for scientific or educational

purposes, check "Donation" and specify the name and location/address of the institution in Items

22 & 23. "Donation" refers only to the entire body, not to individual organs.

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20. SIGNATURE OF FUNERAL DIRECTOR OR PERSON ACTING AS SUCH

When the death certificate is electronically filed in TxEVER by the funeral service licensee assuming

custody of the body and charged with the responsibility for completing the death certificate, this

space will contain the funeral director's name, license number and the statement "by Electronic

Signature".

If another person is acting as licensed funeral director and this person is first assuming custody of

the body and charged with the responsibility for completing the death certificate, this person acting

as a funeral director must sign the record in durable black or blue ink. Rubber stamps or facsimile

signatures are not permitted [HSC Sec. 191.025(d)].

21. UNKNOWN, SECTION, BLOCK, LOT, SPACE

Enter the appropriate information for Section, Block, Lot and Space (niche) to indicate the location

of the burial plot. If the cemetery has no designation of the actual location, Unknown must be

marked. Do not leave this item uncompleted.

 If the cemetery has some designation such as Section, but no Block, Lot, or Space, enter the

Section information and leave the other items blank.

 When designating the location of cremains that are placed in a columbarium, use the spaces

in this item that most closely match. The columbarium may not designate specific locations

in the same manner described on the death certificate, for example, wing, section, row, lot,

space, niche, etc.

 If the cremains are given to the family for disposition, mark "Unknown."

22. PLACE OF DISPOSITION (NAME OF CEMETERY, CREMATORY, OR OTHER

PLACE)

Enter the name of the cemetery, crematory, or other place of disposition.

 If the body is removed from the State, specify the name of the cemetery, crematory, funeral

home, or other place of disposition to which the body is shipped.

 If the body is cremated and the cremains are to be permanently entombed or buried, enter

the name of the cemetery, mausoleum, columbarium, or location where the cremains will be

permanently placed. If the body is being cremated and then entombed or buried, Cremation

should be marked as Method of Disposition. (see item 19)

 If the cremains are given to the family for disposition, enter only the name of the crematory.

 If the body is to be used by a hospital or medical or mortuary school for scientific or

educational purposes, give the name of that institution.

 If the body is being shipped to a foreign country and the location (city or town) is known,

but no information is available regarding the name of the cemetery, enter only the name of

the city or town.

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23. LOCATION (CITY/TOWN, AND STATE)

Enter the name of the city, town, or village and the State where the place of disposition is located.

If the cremains are given to the family for disposition, enter only the city and state in which the

crematory is located.

24. NAME OF FUNERAL FACILITY

Enter the name of the funeral facility or the name of the person acting as funeral director.

If the body is to be used by a hospital, medical, or mortuary school for scientific or educational

purposes, enter the name of that institution. If the person named in item 20 is not a funeral director,

enter the name of that person in this item.

25. COMPLETE ADDRESS OF FUNERAL FACILITY (STREET AND NUMBER, CITY,

STATE, ZIP CODE):

This portion should automatically populate in TxEVER with the funeral facility's address. If this is

the first record you are completing in TxEVER, review that information to insure that information is

correct.

If the person named in item 20 is not a funeral director (exp. a family member acting as a funeral

director), enter the address of that person in this item.

26. CERTIFIER

Mark the appropriate box indicating whether the certifier was a physician, a medical examiner, or a

justice of the peace acting as coroner. A funeral home should have firm knowledge of who will sign

the death certificate as certifier before assuming custody of a body.

For additional information, please refer to the Certifying Death section.

27. SIGNATURE OF CERTIFIER

When the death certificate is electronically filed in TxEVER by the medical certifier that is certifying

to the cause and manner on the death certificate, this space will contain the Medical Certifier's

name , license number and the statement "by Electronic Signature"

28. DATE SIGNED (MONTH DAY YEAR)

TxEVER will automatically complete this portion of the record when the medical certifier

electronically certifies the death certificate. The certifier has five (5) days from the time he or she

receives the death certificate to complete this portion of the certificate and return it to the funeral

director or person acting as such [HSC Sec. 193.005(b)].

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29. LICENSE NUMBER

This will automatically populate with the medical certifier's license number as it is entered in

TxEVER by the TxEver Local Administrator. If this is the first record you are medically certifying

please review this information to insure that it is correct. If certifier is a justice of the peace acting

as coroner, this will automatically be left blank.

30. TIME OF DEATH (ACTUAL OR PRESUMED)

Enter the exact time of death (hours and minutes) according to local time. If daylight-saving time is

the official prevailing time when death occurs, it should be used to record the time of death. Be sure

to indicate whether the time of death is A.M. or P.M. Enter 12 Noon as "12 Noon." One minute after

12 Noon is entered as "12:01 P.M." Enter 12 Midnight as "12 Midnight." A death that occurs at 12

Midnight belongs to the end of the previous day, not the beginning of the new day. One minute after

12 Midnight is entered as "12:01 A.M." of the new day.

Time of Death Type: For the TxEVER Program select one of the following options;

 Actual - The definitive time of death according to available information.

 Presumed - The assumed time of death when the actual time is unknown due to missing

information or a missing person;

 Estimated - The exact time of death is not known but can be approximated based on

documentation; and

 Found - The time at which remains were discovered. [This is usually when a body has been

found after a very extended period of time and time of death cannot be estimated or

presumed.

Note: Do not confuse this item with the time of pronouncement. This item establishes the exact time of

death, which may be important in inheritance cases when there is a question of who died first. This is

often important in the case of multiple deaths in the same family.

31. PRINTED NAME, ADDRESS OF CERTIFIER (STREET AND NUMBER, CITY,

STATE, ZIP CODE)

This portion should automatically populate in TxEVER with the medical certifier's address. If this is

the first record you are completing in TxEVER, review this information to insure that information is

correct.

32. TITLE OF CERTIFIER:

This portion should automatically populate in TxEVER with title of the certifier (i.e. M.D., D.O., M.E.,

J.P., Justice of the Peace, or Medical Examiner) PH.D. is not permitted. If this is the first record you

are completing in TxEVER, review this information to insure that information is correct

33. CAUSE OF DEATH

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Cause of death is the most important statistical research item on the death certificate. It provides

medical information that serves as a basis for describing trends in health and mortality and for

analyzing the conditions leading to death. Mortality statistics provide a basis for epidemiological

studies that focus on leading causes of death by age, race, and sex. They also provide a basis for

research in the course of diseases and diagnostic techniques, which in turn can lead to

improvements in patient care.

Enter the diseases, injuries, or complications that caused the death. Do not enter the mode of dying

such as cardiac or respiratory arrest, shock, or heart failure; enter what caused the cardiac arrest or

heart failure.

If any portion of the cause of death is pending investigation, enter "Pending Investigation" and file

the certificate immediately. Upon determination of the cause of death, an Amendment to Medical

Certification of Certificate of Death should be filed by the physician, medical examiner, or justice of

the peace who originally certified the death. See Chapter 3 for additional information on filing an

Amendment to Medical Certification of Certificate of Death.

PART 1. 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 EACH LINE:

Enter the diseases, injuries, or complications that caused the death. Do not enter the mode of dying

such as cardiac or respiratory arrest, shock, or heart failure. List only one cause on each line.

IMMEDIATE CAUSE [A]

Enter the final disease or condition resulting in death on line a. Do not leave blank. If awaiting the

results of an autopsy or investigation, enter "Pending Investigation."

CONDITIONS LEADING TO IMMEDIATE CAUSE [B,C,D]

 Due to (or as a likely consequence of): Sequentially list conditions, if any, leading to

immediate cause of death.

 Enter underlying cause (disease or injury that initiated events resulting in death) last. The

cause of death means the disease, abnormality, injury, or poisoning that caused the death,

not the mode of dying, such as cardiac or respiratory arrest, shock, or heart failure.

The immediate cause of death is reported on line (a). Antecedent conditions, if any, which gave rise

to the cause are reported on lines (b), (c), and (d). The underlying cause should be reported on the

last line used in Part 1. No entry is necessary on lines (b), (c), and (d) if the immediate cause of

death on line (a) describes completely the sequence of events. Only one cause should be entered on

each line. Additional lines may be added if necessary.

 Approximate Interval: Onset and Death: provide the best estimate of the interval between

the onset of each condition and death. When a precise estimate is not possible, do not leave

the space blank. Entries such as "minutes," "hours," "days," "months" or "years" are useful. If

no estimate is possible, enter "Unknown."

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PART 2. ENTER OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT

RESULTING IN THE UNDERLYING CAUSE GIVEN IN PART 1

In Part 2, enter other important diseases or conditions that contributed to death but did not result

in the underlying cause of death given in Part 1; for example, "substance abuse," "diabetes," or

"smoking."

34. WAS AN AUTOPSY PERFORMED?:

Select "Yes" if a partial or complete autopsy was or will be performed; otherwise, select "No."

Note: An autopsy is important in giving additional insight into the conditions that led to death. This

additional information is particularly important in arriving at the immediate and underlying causes in

violent deaths.

35. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETION OF CAUSE OF

DEATH?

If Was an Autopsy Performed is "No", TxEVER will automatically disable this question and it will be

left blank on the death certificate. Otherwise, select "Yes" if the autopsy findings were available and

used to determine the cause of death; otherwise, select "No."

36. MANNER OF DEATH

Complete this item for all deaths. Select the box corresponding to the manner of death.

General Definitions of Manner of Death:

 Natural - due solely or nearly totally to disease and/or the aging process.

 Accident - there is little or no evidence that the injury or poisoning occurred with intent to

harm or cause death. In essence, the fatal outcome was unintentional.

 Suicide - results from an injury or poisoning as a result of an intentional, self-inflicted act

committed to do self-harm or cause the death of one’s self.

 Homicide - occurs when death results from...an injury or poisoning or from...a volitional act

committed by another person to cause fear, harm, or death. Intent to cause death is a

common element but is not required for classification as homicide.

 Could not be determined - used when the information pointing to one manner of death is no

more compelling than one or more other competing manners of death when all available

information is considered.

 Pending investigation - used when determination of manner depends on further

information.

(Taken from the Nation Center for Health Statistics Medical Examiners' and Coroners' Handbook on

Death Registration and Fetal Death Reporting (2.8M PDF), page 21)

Deaths not due to external causes should be identified as "Natural."

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If the cause of death is anything other than natural the Medical Examiner or Justice of the Peace

should be notified immediately. The Medical Examiner or Justice of the peace conduct an inquest

into the death if [C.C.P. Art.49.04(a)]:

1. the person dies in prison under circumstances other than those described by Section

501.055(b), Government Code, or in jail;

2. the person dies an unnatural death from a cause other than a legal execution;

3. the body or a body part of a person is found, the cause or circumstances of death are

unknown, and:

a. the person is identified; or

b. the person is unidentified;

4. the circumstances of the death indicate that the death may have been caused by unlawful

means;

5. the person commits suicide or the circumstances of the death indicate that the death may

have been caused by suicide;

6. the person dies without having been attended by a physician;

In cases where the immediate cause of death cannot be determined, or the cause of death is pending

investigation, mark the appropriate block and file the certificate immediately. Upon determination

of the cause of death, an Amendment to Medical Certification of Certificate of Death should be filed

by the physician, medical examiner, or justice of the peace that originally certified the death.

Medical amendments are filed without charge. See Chapter 3 for additional information about filing

an Amendment to Medical Certification of Certificate of Death.

37. DID TOBACCO USE CONTRIBUTE TO DEATH?

Check "yes" if, in your clinical opinion, the use of tobacco contributed to the death. Tobacco use may

contribute to deaths due to a wide variety of diseases; for example tobacco use contributes to many

deaths due to emphysema or lung cancer and some heart disease and cancers of the head and neck.

Check "no" if, in your clinical judgment, tobacco use did not contribute to this particular death.

38. IF FEMALE:

If decedent is male select "NOT APPLICABLE" in TxEVER. If the decedent's sex cannot be

determined, select "UNKNOWN IF PREGNANT WITHIN PAST YEAR" in TxEVER.

ITEMS 39 THROUGH 41- INJURY INFORMATION:

Items 39 Through 41 should only be completed if the manner of death is "Accident" "Suicide" or

"Homicide". Only a Medical Examiner or Justice of the Peace can certify to a cause and manner of

death that is not "Natural". At the discretion of the Justice of the Peace or Medical Examiner, items

39 through 41 may be left blank when Manner of Death is marked "Could Not Be Determined."

39. IF TRANSPORTATION INJURY, SPECIFY:

Specify role of decedent (e.g., driver, passenger, pedestrian) in the transportation accident.

Driver/operator and passenger should be designated for modes other than motor vehicles such as

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bicycles. ‘‘Other’’ applies to watercraft, aircraft, animal (riding horseback), or people attached to

outside of vehicles (e.g., ‘‘surfers’’) who are not bonfire passengers or drivers.

Leave blank if injury was not a transportation injury.

40A. DATE OF INJURY (MO/DAY/YYYY):

Enter the exact month, day, and year that the injury occurred. The date of injury might not be the

same as the date of death. In cases in where the exact date is impossible to determine, an estimate

should be made. Select Estimated and then enter the date.

40B. TIME OF INJURY:

Enter the exact time in hours and minutes when the injury occurred. Use prevailing local time. For

cases where the exact time is impossible to determine an estimate should be made; for example,

select "Approximately" and then "10:30 A.M." Be sure to indicate whether the time of injury was

A.M. or P.M.

40C. INJURY AT WORK?

Complete if anything other than natural disease is mentioned in Part uI or Part II of the medical

certification (item 33), including homicides, suicides, and accidents or if anything other than

natural is checked for manner of death (item 36). This includes all motor vehicle deaths. The item

must be completed for decedent’s ages 14 years or over and may be completed for those less than

14 years of age if warranted. Enter ‘‘Yes’’ if the injury occurred at work. Otherwise enter ‘‘No.’’ An

injury may occur at work regardless of whether the injury occurred in the course of the decedent’s

‘‘usual’’ occupation.

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Examples Of Injuries At Work

Examples of Injuries NOT At Work

Injury while working or in vocational training

on job premises

Injury while on break or at lunch or in parking

lot on job premises

Injury while working for pay or compensation,

including at home

Injury while working as a volunteer law

enforcement official, etc.

Injury while traveling on business, including to

or from business contacts

Injury while engaged in personal recreational

activity on job premises

Injury while a visitor (not on official work

business) to job premises

Homemaker working at homemaking activities

Student in school

Working for self for no profit (mowing yard,

repairing own roof, hobby)

Commuting to or from work

The above guidelines were developed jointly by: The National Association for Public Health

Statistics and Information Systems (NAPHSIS), the National Institute of Occupational Safety and

Health (NIOSH), the National Center for Health Statistics (NCHS), and the National Center for

Environmental Health and Injury Control (NCEHIC).

Examples Of Injury At Work And Injury Not At Work

40D. PLACE OF INJURY (E.G. DECEDENT'S HOME, CONSTRUCTION SITE, RESTAURANT,

WOODED AREA):

Enter the general type of place (such as restaurant, vacant lot, baseball field, construction site, office

building, or decedent’s home) where the injury occurred. DO NOT enter firm or organization names.

(For example, enter ‘‘factory,’’ not ‘‘Standard Manufacturing, Inc.’’)

40E. LOCATION (STREET AND NUMBER OR RURAL ROUTE, CITY OR TOWN, STATE):

Enter the complete address where the injury took place. If there is no address, describe the

location; for example, "Hwy. 30, 2 mile east of the FM 29."

40F. COUNTY OF INJURY:

Enter the county in which the injury occurred.

Please note: This may different than the "County of Death"

41. DESCRIBE HOW INJURY OCCURRED:

Briefly and clearly describe how the injury occurred, explaining the circumstances or cause of the

accident or injury, such as "fell off ladder while painting house," "ran off roadway," or "car/truck

collision."

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For firearm related deaths, indicate the type of gun, such as handgun, shotgun, hunting rifle, or

military firearm.

For motor vehicle accidents, specify type of vehicle (pick-up truck, car, motorcycle, etc.).

If known, indicate what activity the decedent was engaged in when the injury occurred (e.g., playing

a sport, working for income, hanging out at a bar).

42A-C: LOCAL REGISTRAR FILE INFORMATION

42A. REGISTRAR FILE NUMBER

The local registrar enters the appropriate file number. The number consists of the registrar's

unique two digit number (registration location number) and the file number separated by dashes

or spaces. The year may also be used if desired and must be shown after the file number and

preceded by a dash or space.

The local registrar consecutively numbers the certificates in separate series beginning with the

number "1" for the first certificate of each type in each calendar year. For example, a registrar

assigned the number "02" enters the following number for the first death certificate completed in a

year: "02-1", or "02 1." The use of leading zeros in the file number section is also permitted; for

example, "02 001." If the registrar wishes to use the year in the file number, it would read: "02-001-

2010" or "02-001-10."

If the local registrar file number is too long to put in TxEVER, you may eliminate the spaces in the

number. For example "02-001-10" may be entered into TxEVER as "0200110."

42B. DATE RECEIVED BY LOCAL REGISTRAR:

The local registrar enters the date the certificate was received, accepted, and filed in his or her

office. This item documents whether the certificate was filed within the time period specified by

law.

42C. REGISTRAR:

The local registrar for the district in which the event occurred signs the certificate when it is

accepted and filed. The signature may be either handwritten or facsimile stamped with durable

black or blue ink.

For fully electronic records, a signature is not needed. TxEVER will complete this item with

information indicating that the record was electronically filed and with which local registrar it is

filed with (Exp. "Registrar - Dallas County Clerk, Electronically Filed").

ITEMS 43 THROUGH 49:

These items cannot be left blank.

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43. DECEDENT'S EDUCATION:

Select the highest number of years of regular schooling completed by the decedent. Report only

those years of school that were completed.

CHECK THE BOX THAT BEST DESCRIBES THE HIGHEST DEGREE OF LEVEL OF SCHOOL

COMPLETED AT THE TIME OF DEATH.

If the decedent was currently enrolled in school, check the box that indicates the previous grade or

highest degree received.

A person who enrolls in college but does not complete one (1) full year should not be identified

with any college education in this item; that is, enter "High School Graduate of GED completed"

Count elementary, secondary, and college education only. Do not include beauty, barber, trade,

business, technical, or other special schools when determining the highest grade completed.

Type "Unknown" if decedent's education is not known.

44. DECEDENT OF HISPANIC ORIGIN?

Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. The response

should reflect what the decedent considered him-self or herself to be. Select only one response.

Check the "No" box if decedent is not Spanish/Hispanic/Latino. If the decedent's Hispanic

designation is not listed, check the "Yes, Other" box and enter the decedent's Hispanic origin on the

(Specify) line.

Each question, Race and Hispanic Origin, should be asked independently. ‘‘Hispanic’’ is not a race,

and a decedent of Hispanic origin may be of any race (White, Black or African American, Native

American, etc.) . ‘‘Hispanic’’ is a self-designated classification for people whose origins are from

Spain, the Spanish-speaking countries of Central or South America, the Caribbean, or those

identifying themselves generally as Spanish or Spanish-American. Origin can be viewed as ancestry,

nationality, or country of birth of the person or person’s parents or ancestors prior to their arrival

in the United States. Although the prompts include the major Hispanic groups, other groups may be

specified under ‘‘Other.’’

If the informant does not know, select ‘‘Unknown.’’

If there is no informant, select ‘‘Unknown.’’

If informant refuses to provide this information, select ‘‘Unknown.’’

Note: Hispanics comprise a substantial population group within this country. Reliable data are

needed to identify and assess public health problems of Hispanics. Information from item 44 will

permit the production of mortality data for the Hispanic community. Identifying health problems

will make it possible to target public health resources to this important segment of our population.

45. DECEDENT'S RACE:

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Enter the race or races of the decedent as stated by the informant. Each question, Race and Hispanic

origin, should be asked independently. Do not leave item 45 blank. If there is no box for the

informant’s response for one or more race, check the box ‘‘Other’’ and enter the informant’s literal

(written) response even if the response is not a race or race(s). Do not make assumptions.

American Indian and Alaska Native refer only to those native to North and South America

(including Central America) and does not include Asian Indian. Please specify the name of enrolled

or principal tribe (e.g., Navajo, Cheyenne, etc.) for the American Indian or Alaska Native.

For Asians and Pacific Islanders, enter the national origin of the decedent. For Asians check Asian

Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or specify other Asian group; for Pacific

Islanders check Native Hawaiian, Guamanian or Chamorro, Samoan, or specify Other Pacific

Islander.

If more than one race is indicated, enter each race (e.g., Samoan-Chinese-Filipino or White,

American Indian).

If there is no informant or other reliable source of this information, select If the respondent does

not know, enter ‘‘Unknown.’’ If the informant refuses to provide this information, select "Unknown."

Note: Race is essential for identifying specific mortality patterns and leading causes of death among

different racial groups. It is also used to determine if specific health programs are needed in

particular areas and to make population estimates.

46. EVER IN U.S. ARMED FORCES?

Mark "Yes" if the decedent was ever in any of the U.S. Armed Forces; if not, mark "No."

If "yes", complete "If decedent served in U.S. Armed Forces, Fill Out The Following:" portion located

on the back to the death certificate.

 Is the decedent 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?

 Post office address (this would be the mailing address of the next of kin or next of friend)

47. EVER A PEACE OFFICER IN THIS STATE?

Mark "Yes" if the decedent was ever a peace officer in the state of Texas; if not, mark "No". If the

decedent was never a peace officer in Texas but was a peace officer in another state, mark "No".

48. DECEDENT'S USUAL OCCUPATION:

Enter the usual occupation of the decedent. This means the type of job the individual was engaged

in for most of his or her working life. It is not necessarily the highest paid job nor the job considered

the most prestigious, but the one occupation, of perhaps several, that accounted for the greatest

number of working years. For example, usual occupation may include claim adjuster, farmhand,

coal miner, janitor, store manager, college professor, or civil engineer.

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Never enter ‘‘Retired.’’

If the decedent was a homemaker at the time of death but had worked outside the household

during his or her working life, enter that occupation.

If the decedent was a ‘‘homemaker’’ during most of his or her working life, or never worked outside

the household, enter ‘‘Homemaker.’’ Enter ‘‘Student’’ if the decedent was a student at the time of

death and was never regularly employed or employed full time during his or her working life.

If not known, enter ‘‘Unknown.’’

49. TYPE OF BUSINESS/INDUSTRY

Enter the type of business or industry to which the decedent's usual occupation relates (e. g.,

farming, legal, hardware store, retail clothing, university, government, etc.). Do not enter firm or

organization's name.

 If the decedent was a homemaker for most of his or her working life, and "Homemaker" is

enter as the decedent's usual occupation, enter "Own Home" or "Someone else's Home,"

whichever is appropriate.

 If the decedent was a student at the time of death and "Student" is entered as the decedent's

usual occupation (Item 48), enter the type of school, not enter the actual school name (exp.

enter "high school" or "college" not "South City High School").

If not known, enter ‘‘Unknown.’’

Note: These items are useful in studying occupationally related mortality and in identifying job-related

risk areas. For example, correlating asbestos used in particular occupations in the shipbuilding

industry to respiratory cancer was possible with this information.