McCoy & Harrison Funeral Home

State of Texas Certificate of Death


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?  

Instructions for Filing a Texas Certificate of Death  

All information except signatures should be typed. If it is not possible to type the information, print  legibly using durable black or blue ink. All signatures must be handwritten in durable black or blue  ink (unless signed electronically in Texas Electronic Registrar described below). Rubber stamps or facsimile signatures are not permitted [HSC §191.025(d)] for funeral directors and certifiers.  Complete each item following the requirements for that specific item. These instructions can be  found online at www.dshs.state.tx.us/vs/fie/d/handbooks/deacont.shtm or in the Texas Vital Statistics 

Handbook on Death Registration.  

Do not leave a space blank unless specifically instructed to do so. Avoid using correction fluid. Do not make alterations, erasures, or strike-overs. Obvious changes affect the validity of a certificate.  Altered certificates may be rejected by the local registrar or Texas Vital Statistics. Avoid abbreviations except for those suggested in the item-by-item specific instructions. Verify the spelling of all names and numbers with the informant.  

A Certificate of Death must be filed within ten (10) days of the date of death for every death in  Texas. It must be filed with the local registrar in the district where the death occurred or the body was found [HSC §193.003(a)].  

The Certificate of Death must be filed by the person in charge of interment or disposition, or by the person in charge of removing the body from the registration district for disposition [HSC § 193.002].  

The certifier is responsible for verifying the date of death in Item 2 and completing the medical certification portion of the Texas Certificate of Death (Items 26 through 39). The certifier must complete the medical certification not later than five (5) days after receiving the record or provide notification to the funeral director, or person acting as such, explaining the reason for the delay [HSC  §193.005(b)(g)].  

If the manner of death is other than natural, the justice of the peace or medical examiner should be called immediately. Physicians should not certify suicides, homicides, or accidental deaths. A  medical examiner should also be notified if a death occurs within 24 hours of admission to a hospital  (regardless of the manner of death).  

A current death certificate can only be filed within one year of the date of death. If a death certificate has not been filed within one (1) year, a Court-Ordered Delayed Certificate of Death should be filed.  

If the cause of death is pending investigation, the certifier should enter "Pending Investigation" and file the certificate immediately. Upon determination of the cause of death, an Amendment to Medical  Certification of Certificate of Death (VS-174) should be filed by the physician, medical examiner, or justice of the peace who originally certified the death.  

TER (Texas Electronic Registration) - Death is a free online Internet death registration system available through the  Texas Vital Statistics office. A user can start and complete his or her portion of the Certificate of Death without having to leave the office or wait for the other parties to complete their portions.  

Licensed funeral directors, physicians, justices of the peace, medical examiners, and local registrars may complete their portion of the Certificate of Death and electronically sign it at their own computer. Timeliness prompts will warn users to complete their portion so that the Certificate of Death will be filed in a timely matter. The Social Security number of the deceased is verified by the Social Security Administration in real-time. A Report of Death is sent electronically to the local registrar and funeral directors may print a paper copy of that report for themselves.  

More information on participating in online death registration is available at: www.dshs.state.tx.us/vs/edeath or contact the Texas Vital Statistics office at 888-963-7111 ext.3303. 

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Signature Certificate
Document name: State of Texas Certificate of Death
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November 16, 2020 8:19 am CSTState of Texas Certificate of Death Uploaded by Brandon Lee - bayne@baynedm.com IP 110.54.240.123