State of Texas
Certificate of Death

STATE FILE NUMBER

TEXAS DEPARTMENT OF STATE HEALTH SERVICES - VITAL STATISTICS UNIT
  1. LEGAL NAME OF DECEASED: MAIDEN:  
  2. DATE OF DEATH: (ACTUAL OR PRESUMED)
  3. SEX:
  4. DATE OF BIRTH:
  5. AGE: If under 1 year:
    If under 1 day:
  6. BIRTHPLACE:
  7. SOCIAL SECURITY NUMBER:  
  8. MARITAL STATUS AT TIME OF DEATH:
     
  9. SURVIVING SPOUSE'S NAME:  
  10. ADDRESS: 10g. INSIDE CITY LIMITS?
     
  11. FATHER'S NAME:
  12. MOTHER'S NAME PRIOR TO FIRST MARRIAGE:  
  13. PLACE OF DEATH (CHECK ONLY ONE):
    IF DEATH OCCURRED IN A HOSPITAL:
    IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
     
  14. COUNTY OF DEATH:  
  15. CITY/TOWN, ZIP CODE:  
  16. FACILITY NAME:  
  17. INFORMANT'S NAME & RELATIONSHIP TO DECEASED:  
  18. MAILING ADDRESS OF INFORMANT:  
  19. METHOD OF DISPOSITION:
     
  20. SIGNATURE AND LICENSE NUMBER OF FUNERAL DIRECTOR OR PERSON ACTING AS SUCH: See signature below.
  21. UNKNOWN 
     
    Section  
    Block  
    Lot  
    Space  
  22. PLACE OF DISPOSITION:
     
  23. LOCATION:
  24. NAME OF FUNERAL FACILITY:  
  25. COMPLETE ADDRESS OF FUNERAL FACILITY:  
  26. CERTIFIER: (Check only one)
     
  27. SIGNATURE OF CERTIFIER: Please see the signature below.
  28. DATE CERTIFIED: (Mo/Day/Yr)
  29. LICENSE NUMBER:  
  30. TIME OF DEATH:  
  31. PRINTED NAME, ADDRESS OF CERTIFIER:  
  32. TITLE OF CERTIFIER:  


    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.

    IMMEDIATE CAUSE (Final disease or condition ------> resulting in death)
    a.  

    Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or injury that initiated, the events
    resulting in death) LAST
    b.  
    c.   
    d.   

    PART 2. ENTER OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE UNDERLYING CAUSE GIVEN IN PART I.
     

  34. WAS AN AUTOPSY PERFORMED?
     
  35. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH?
     
  36. MANNER OF DEATH:
     
  37. DID TOBACCO USE CONTRIBUTE TO DEATH?
     
  38. IF FEMALE:
     
  39. IF TRANSPORTATION INJURY, SPECIFY:
     

  40. a. DATE OF INJURY: b. TIME OF INJURY: c. INJURY AT WORK?
    d. PLACE OF INJURY: e. LOCATION: f. COUNTY OF INJURY:  
  41. DESCRIBE HOW INJURY OCCURRED:
     
  42. a. REGISTRAR FILE NO.: b. DATE RECEIVED BY LOCAL REGISTRAR: c. REGISTRAR:  

    INFORMATION ON BACK OF THE FORM MUST BE COMPLETED IF APPLICABLE

     INFORMATION BELOW IS FOR STATISTICAL PURPOSES ONLY AND IS NOT TO BE INCLUDED ON CERTIFIED COPIES

  43. DECEDENT'S EDUCATION (Check the box that best describes the highest degree or level of school completed at the time of death)
  44. DECEDENT OF HISPANIC ORIGIN? (Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check the "No" box if decedent is not Spanish/Hispanic/Latino)
     
  45. DECEDENT'S RACE (Check one or more races to indicate what the decedent considered himself or herself to be)
     
     
  46. EVER IN U.S. ARMED FORCES?
     
  47. EVER A PEACE OFFICER IN THIS STATE?
     
  48. DECEDENT'S USUAL OCCUPATION:  (Indicate type of work done during most of working life. DO NOT USE RETIRED)  
  49. TYPE OF BUISNESS/INDUSTRY:  

    IF DECEASED SERVED IN U.S. ARMED FORCES, FILL OUT THE FOLLOWING:

    Is the deceased reported to have been in such service? 
     
    Name of organization in which service was rendered?  
    Serial number of discharge papers or adjusted service certificate?  
    Name of next of kin or of next friend?  
    Post Office Address?  

 

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Signature Certificate
Document name: State of Texas Certificate of Death
lock iconUnique Document ID: 2d3d11ae725a04bd650ca8f9cbf458bbd9505476
Timestamp Audit
November 16, 2020 8:19 am CSTState of Texas Certificate of Death Uploaded by Brandon Lee - bayne@baynedm.com IP 112.204.164.158
March 21, 2022 7:41 am CSTCrystal Mccoy - crystal@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 21, 2022 7:41 am CSTBrandon Lee - brandon@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 21, 2022 7:46 am CSTCrystal Mccoy - crystal@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 21, 2022 7:46 am CSTBrandon Lee - brandon@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 9:33 pm CSTCrystal Mccoy - crystal@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 9:33 pm CSTBrandon Lee - brandon@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 9:36 pm CSTCrystal Mccoy - crystal@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 9:36 pm CSTBrandon Lee - brandon@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 9:41 pm CSTCrystal Mccoy - crystal@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 9:41 pm CSTBrandon Lee - brandon@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 9:46 pm CSTCrystal Mccoy - crystal@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 9:46 pm CSTBrandon Lee - brandon@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 24, 2022 10:14 pm CSTCrystal Mccoy - crystal@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.204.164.158
March 24, 2022 10:14 pm CSTBrandon Lee - brandon@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.204.164.158