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State of Texas
Certificate of Death

STATE FILE NUMBER

TEXAS DEPARTMENT OF STATE HEALTH SERVICES - VITAL STATISTICS UNIT

LEGAL NAME OF DECEASED: MAIDEN:
DATE OF DEATH: (ACTUAL OR PRESUMED)
SEX:
DATE OF BIRTH:
AGE: If under 1 year:
If under 1 day:
BIRTHPLACE:
SOCIAL SECURITY NUMBER:
MARITAL STATUS AT TIME OF DEATH:
SURVIVING SPOUSE'S NAME:
ADDRESS: 10g. INSIDE CITY LIMITS?
YES

NO
FATHER'S NAME:
MOTHER'S NAME PRIOR TO FIRST MARRIAGE:
PLACE OF DEATH (CHECK ONLY ONE):
IF DEATH OCCURRED IN A HOSPITAL:
INPATIENT

ER PATIENT

DOA

IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
Hospice Facility

Nursing Home

Decedent's Home

Other (Specify)
COUNTY OF DEATH:
CITY/TOWN, ZIP CODE:
FACILITY NAME:
INFORMANT'S NAME & RELATIONSHIP TO DECEASED:
MAILING ADDRESS OF INFORMANT:
METHOD OF DISPOSITION:
Burial

Cremation

Donation

Entombment

Removal from state

Other (Specify)
SIGNATURE AND LICENSE NUMBER OF FUNERAL DIRECTOR OR PERSON ACTING AS SUCH: See signature below.
UNKNOWN
YES

Section
Block
Lot
Space
PLACE OF DISPOSITION:
LOCATION:
NAME OF FUNERAL FACILITY:
COMPLETE ADDRESS OF FUNERAL FACILITY:
CERTIFIER: (Check only one)
Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated.

Medical Examiner/Justice of the Peace - On the basis of examination, and/or investigation, in my opinion, death occurred at the time,date and place, and due to the cause(s) and manner stated.
SIGNATURE OF CERTIFIER: Please see the signature below.
DATE CERTIFIED: (Mo/Day/Yr)
LICENSE NUMBER:
TIME OF DEATH:
PRINTED NAME, ADDRESS OF CERTIFIER:
TITLE OF CERTIFIER:
```
CAUSE 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.

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.
WAS AN AUTOPSY PERFORMED?
YES

NO
WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH?
YES

NO
MANNER OF DEATH:
Natural

Accident

Suicide

Homicide

Pending Investigation

Could not be determined
DID TOBACCO USE CONTRIBUTE TO DEATH?
YES

NO

PROBABLY

UNKNOWN
IF FEMALE:
Not pregnant within past year

Pregnant at time of death

Not pregnant, but pregnant within 42 days of death

Not pregnant, but pregnant 43 days to one year before death

Unknown if pregnant within the past year
IF TRANSPORTATION INJURY, SPECIFY:
Driver/Operator

Passenger

Pedestrian

Other (Specify)
a. DATE OF INJURY: (Mo/Day/Yr) b. TIME OF INJURY: c. INJURY AT WORK?
YES

NO

d. PLACE OF INJURY: e. LOCATION: f. COUNTY OF INJURY:
DESCRIBE HOW INJURY OCCURRED:
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
DECEDENT'S EDUCATION (Check the box that best describes the highest degree or level of school completed at the time of death)
8th grade or less

9th - 12th grade, no diploma

High school graduate or GED completed

Some college credit, but no degree

Associate degree (e.g., AA, AS)

Bachelor's degree (e.g., BA, AB, BS)

Master's degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)
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)
No, not Spanish, Hispanic/Latino

Yes, Mexican, Mexican American, Chicano

Yes, Puerto Rican

Yes, Cuban

Yes, other Spanish/Hispanic/Latino
DECEDENT'S RACE (Check one or more races to indicate what the decedent considered himself or herself to be)
White

Black or African American

American Indian or Alaska Native

Asian

Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian (Specify)

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander (Specify)
EVER IN U.S. ARMED FORCES?
YES

NO
EVER A PEACE OFFICER IN THIS STATE?
YES

NO

OTHER
DECEDENT'S USUAL OCCUPATION: (Indicate type of work done during most of working life. DO NOT USE RETIRED)
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?
YES

NO

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?

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

November 16, 2020 8:19 am CST

State of Texas Certificate of Death Uploaded by Brandon Lee - bayne@baynedm.com IP 112.204.164.158

March 21, 2022 7:41 am CST