Healthcare Death Facts Form

HEALTHCARE DEATH FACTS FORM

Decedent Information

Date of Birth: / /

Event and Pronouncement

Date of Death: / /

Time of Death:

Location Type: Hospital inpatient Emergency department Residence Hospice Other

Pronounced by: Title:

License or Identification Number: Pronouncement Time:

Medical Cause of Death

Immediate Cause (final disease, injury or complication directly causing death):

Underlying Cause(s) (diseases, conditions, or injuries that led to the immediate cause):

Other Significant Conditions Contributing to Death (but not part of the causal sequence):

Interval between onset and death for the immediate cause:

External Factors and Investigation

Manner of Death: Natural Accident Suicide Homicide Pending/Under Investigation Unknown

If external cause applies, describe circumstances and location:

Was an autopsy performed? Yes No If yes, performed by:

Resuscitation, Advance Directives, and Donation

Was cardiopulmonary resuscitation (CPR) attempted? Yes No

Was there a Do-Not-Resuscitate (DNR) order or advance directive in effect? Yes No If yes, location of documentation:

Organ/tissue donation authorized? Yes No Unknown

If donation occurred, organs/tissues recovered and facility:

Medical History and Treatments

Current Medications:

Known Allergies:

Significant Past Medical History (surgeries, chronic conditions):

Next of Kin / Notification

Relationship: Contact Phone:

Notification Date: / / Time Notified:

Certification and Legal Attestation

I certify, under penalty of law, that the information contained on this Healthcare Death Facts Form is true and accurate to the best of my knowledge. This record is made for the purpose of medical certification and may be relied upon for legal, statistical, and public health purposes. Misrepresentation of material facts on this form may subject the signer to civil or criminal penalties as provided by law.

By signing below, the signer declares that they are the certifying clinician or an authorized representative with knowledge of the decedent's medical history and circumstances of death. If signed by an authorized representative rather than the certifying clinician, the representative must indicate their relationship to the decedent and provide authority for signing.

Certifier Contact Phone: Certifier Email/Contact:

Authorization For Release and Record Retention

By completing and signing this form, the certifier authorizes release of the contained factual and medical information to registrars, public health authorities, and other parties as required by law for death certification, vital statistics, and public health investigation. This form is retained as part of the decedent's medical record in accordance with applicable record retention policies.

Authorization Expiration Date (if applicable):

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