INTRODUCTION — Death certificate completion and appropriate medical examiner involvement after death are important components of patient care. Training in proper death certificate completion is likely inadequate or may be completely lacking, and mistakes are common. This has implications for the individual and for accurate monitoring of mortality data. This topic will provide education on correctly completing a death certificate and describe the role of the medical examiner/coroner in death investigations.
PURPOSE OF THE DEATH CERTIFICATE — The death certificate serves three basic purposes :
●It documents a death (registration process)
●It provides an opinion regarding the cause, circumstances, and manner of death (certification process)
●It provides information that may be used for public health benefits
At the local, state, or national level, death certificate information is used by government and other agencies for monitoring morbidity and mortality, scientific study, legislative change, research and funding prioritization, public health strategies and public safety initiatives, closure of estate and life insurance claims, and even ancestry information [2-6].
The importance of accurate and complete death certificate information cannot be overstated. It is of critical importance that it is completed fully and accurately [7-10]. However, it has been estimated from various studies that 33 to 40 percent of death certificates completed in an academic medical institution in the United States had a major error in the cause of death statement .
HOW TO COMPLETE A DEATH CERTIFICATE — The information below is relevant to United States death certificates, and an example of which is provided in the graphic (form 1).
Components — The death certificate contains medical information, (which is authored by medical providers, medical examiners, or coroners), and information regarding patient demographics, ancestry, and the disposition of remains (eg, cremation, burial), which is filled out by a funeral director.
A fully executed death certificate will contain signatures from several individuals to attest that the death has occurred (pronouncer), describe the medical cause of death (certifier), describe the disposition of remains (funeral director), and indicate that the certificate is registered (Vital Records staff). These signatures may be on paper, although in many jurisdictions the process is electronic within an electronic death registry. The data from the death certificate are shared at the local, statewide, and national levels with the National Center for Health Statistics (NCHS) at the US Centers for Disease Control and Prevention (CDC). The credentials of the signatories are defined legally within each health department jurisdiction.
Medical information — The medical information includes the pronouncement of death as well as the medical certification of the cause of death. The location of the death dictates who will complete the medical information section of the certificate. In general, after a natural death in a medical facility, this section would be completed by the treating physician or advanced practitioner. After a natural home death, it may be completed by the primary care physician. Some death certificates occurring in either location, however, must be completed by a medical examiner/coroner. (See 'Deaths reportable to medical examiner/coroner' below.)
Pronouncement — This information is completed by a person with medical training who is capable of determining death (eg, nurses, APRNs, PAs, MD/DO, medical examiner/coroner). For out-of-hospital deaths, an emergency medicine physician may pronounce death over the phone in consultation with emergency medical services or paramedics.
Death is defined in two ways: as the irreversible cessation of circulatory and respiratory functions, or the irreversible cessation of all functions of the entire brain including the brain stem (death by neurologic criteria)  (see "Diagnosis of brain death"). The type of definition used may affect the date and time of pronouncement. For example, a person may be declared dead by neurologic criteria but still have a beating heart. In that instance, the pronouncement time is when they were declared dead by neurologic criteria, not when the heart eventually stops.
Medical certification of death — The medical cause of death section of the certificate has two components: the cause of death (Part 1) and contributing conditions (Part 2) . Not every death will have a Part 2. These must be completed by a MD/DO or medical examiner/coroner. An APRN, PA, or a nurse also may complete the certificate if a doctor has issued an order allowing them to do so.
Documenting the cause of death — A misconception among many clinicians is that they must be 100 percent certain of the cause to certify the death. This is never the case. For a natural death, the required degree of certainty is a medical probability, that is to say: more likely than not, this person died of this disease. The cause of death is an opinion based upon the available medical history information, risk factors for disease, and circumstances.
The death certificate documents the cause of death by potentially describing three components: (table 1)
●Underlying cause of death
However, the most important of these is the underlying cause because this is the only one that provides information on the condition responsible for the death and is the only one that is required. Not all deaths have an obvious mechanism or immediate cause of death and death certificates do not require a mechanism or immediate cause. When documented, the three conditions should have a causal relationship to one another within a single disease process or continuum. A description of this causal relationship is called a "cause of death statement." Several examples of proper documentation for different patient scenarios are provided in the table (table 1).
●Mechanism – Mechanisms of death are the alterations of physiology and biochemistry whereby the underlying causes exert their lethal effects. These mechanisms are never etiologically specific and cannot stand by themselves on a death certificate. They are caused by a variety of diseases and injuries. Examples include disseminated intravascular coagulation, sepsis, cardiac arrhythmias, acidosis, asphyxiation, and exsanguination.
●Immediate cause – Immediate causes of death are complications of the underlying cause interposed between the underlying cause and fatal result. There may be one or more immediate causes, and they may occur over a brief or prolonged interval, but none absolves the underlying cause of its ultimate responsibility. Similar to mechanisms, immediate causes are not etiologically specific and cannot stand alone on the death certificate. Examples include bronchopneumonia, acute pancreatitis, congestive heart failure, myocardial infarct, and pulmonary thromboembolism.
●Underlying cause – The underlying cause of death is the etiologically specific disease (and/or injury) that started the lethal sequence of events. It is defined as that which, in a natural and continuous sequence, unbroken by any efficient intervening cause, produces the fatality, and without which the death would not have occurred. The underlying cause should be thought of as a "codeable" disease, a disease in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) . Examples include atherosclerosis, diabetes mellitus, colonic adenocarcinoma, senile or Alzheimer-type dementia, and pulmonary emphysema.
An example of these three components used to create a cause of death statement would be hemopericardium with cardiac tamponade (mechanism) due to ruptured myocardial infarct (immediate cause) due to atherosclerotic coronary artery disease (underlying cause). Myocardial infarct cannot be the underlying cause because a variety of etiologically specific causes may result in a myocardial infarct (eg, coronary arteritis, acute cocaine intoxication).
For each of these components, the death certificate has a column to indicate the best estimate of the "approximate interval" between the onset of the condition and the death. These intervals are meant to assist with the understanding of pathophysiology. Appropriate entries to this column are "years," "months," "days," "hours," "minutes," "seconds," or "unknown."
Contributing conditions — Some deaths, but certainly not all, have a contributing condition, and these are important to include [3,15]. An example of a contributing condition is pulmonary emphysema in a person who dies of atherosclerotic cardiovascular disease. In this instance, the lung disease likely caused a physiologic condition that exacerbated the cardiac disease. By contrast, an example of a disease that would not qualify as a contributing condition in this patient might be arthritis. Contributing conditions can be general (eg, cirrhosis of the liver, anemia, aortic stenosis, chronic kidney disease) or may be etiologically specific diseases (eg, diabetes mellitus, obesity).
COVID-19 documentation — The coronavirus disease 2019 (COVID-19) pandemic has put a significant strain on the medical system and the vital records systems nationwide as it relates to mortality data. Accurate and timely death certification is a necessity [16,17]. The CDC provides information on how to certify these deaths.
Common mistakes/misconceptions — Errors on death certificates are common [4,9,10,18-29]. Several are described below:
●Lack of logical flow – The death certificate has four lines to organize the flow of the cause of death statement (mechanism, immediate cause, underlying cause, and contributing conditions), each of which should relate to one another in a logical way. They are not four separate lines for four separate distinct disease processes without a pathophysiologic connection. The certificate is meant to have the most important/underlying condition on the bottom-most line. However, there is a tendency to put the most important diagnosis first (eg, atherosclerotic cardiovascular disease due to myocardial infarct). This is the "cart before the horse" error and results in a logic error when one considers the "due to" phrasing. The death certificate is read from the top to bottom, with each line connected by a "due to"; therefore, the four lines need to all relate to one another within a single disease process or continuum. It is important for this to be understood as those lines of text are converted to codes by vital record agencies.
●Writing more than is needed – It is not necessary to use all four lines. The most important (underlying) cause needs to be on the bottom-most line, often the only line that is utilized in some cases (eg, hypertensive cardiovascular disease).
●Not recognizing the underlying cause – All certificates must report an underlying cause of death, but some clinicians mistake an immediate cause for an underlying one. An example of this would be if the death certificate only lists acute bronchopneumonia, which is an immediate cause of death which requires an underlying cause. Bronchopneumonia is a patchy consolidation involving one or more lobes contrasted with a lobar pneumonia involving an entire lobe. It is not an etiologically specific cause because many diseases may lead to it; to make this a correct certificate, there needs to be documentation of underlying cause of the bronchopneumonia (eg, SARS-CoV-2 [COVID-19] respiratory infection, pulmonary emphysema, metastatic pancreatic adenocarcinoma). It should be noted that a lobar pneumonia (a typical pneumococcal pneumonia) is a different disease process than a bronchopneumonia. Lobar pneumonia can occur without any underlying health condition, and so it may stand alone on the death certificate.
Two other examples in which the certifier may neglect to include an underlying cause of death are myocardial infarcts and end-stage kidney disease. The reason for the myocardial infarct must be listed, and although most myocardial infarcts are due to coronary artery atherosclerosis, some may be due to a vasculitis or stimulant abuse. For end-stage kidney disease, the underlying disease (eg, diabetes, hypertension, systemic lupus erythematosus) must be included.
●Inappropriate use of cardiopulmonary arrest – Cardiopulmonary (or cardiac or respiratory) arrest continues to be listed as the cause of death on death certificates. Cardiopulmonary arrest simply means the heart and lungs have stopped. It is a synonym for death and is redundant to list it in the cause of death statement. Every death, no matter the cause, results in a cardiopulmonary arrest. The question is, what is the disease that caused the cardiopulmonary arrest? Specific cardiac arrhythmias also are not accurate causes of death. Asystole and ventricular fibrillation essentially occur with every death. On the standard United States death certificate, it states: "DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology." The cause of death needs to be a specific disease entity that caused the arrhythmia.
●Misuse of contributory conditions – Contributory conditions are not meant to be a problem list, a place for unusual or interesting diagnoses, or a notation of a patient's medical history. These conditions are listed only if they have made a physiologic contribution to the death.
Manner of death — The manner of death is an explanation of how the cause arose or the circumstances for how an injury occurred. The choices for the manners of death are natural, accident, suicide, homicide, undetermined, and therapeutic complication (in some parts of the United States). Natural deaths are those caused exclusively (100 percent) by disease or old age. A natural death certificate can be issued by a medical practitioner.
If any injury (physical or chemical) contributes to death, the death is not classified as natural. These deaths must be reported to the governmental medical examiner/coroner as only they can certify unnatural deaths. In fact, there may be no place on the usual "hospital" death certificate for the manner of death because they should all be natural. Violent (traumatic) deaths are further classified as accident, homicide, or suicide. In rare instances, the manner of death also may be certified as undetermined when the circumstances and findings leave reasonable doubt about the classification.
Therapeutic complication may be considered as the manner of death when a medical/surgical intervention was performed as usual but had a known complication that hastened death. An example would be an allergic reaction to penicillin for treatment of a bacterial pharyngitis. A therapeutic complication may be distinguished from a natural manner by asking the "but for" question. If the patient would not have died at this time "but for" the complication of therapy, it may be a therapeutic complication and may be reportable to the medical examiner/coroner [30,31].
Death certificates have a special injury section for use only by the medical examiner/coroner. This section includes the manner of death and specific injury information including the date, time, and location of injury; type of place of injury; and a narrative description of how the injury occurred .
Required questions (pregnancy, tobacco, work-related) — The National Center for Health Statistics often recommends that certain risk factors or states be tracked on death certificates. Currently there are questions that ask whether or not tobacco contributed to the death (acceptable answers include “unknown” or “probably”), if the person was pregnant at or within a year of the death, whether or not an autopsy was performed, and whether a work-related injury resulted in the death.
Demographics/vital records — This section is completed by the funeral director during an interview with the next of kin. The demographic information typically includes legal name, sex, date of birth, birthplace, residence at time of death, marital status, parents' names, occupation, veteran status, educational level, Social Security number, and the name of the informant. The disposition of the remains is notated as burial, cremation, anatomic gift, or burial at sea, and the name of funeral home, embalmer, and site of crematory or cemetery are listed. The date of final disposition also is included.
Deaths reportable to medical examiner/coroner — Deaths that are reportable to the governmental medicolegal death investigation authority (either the medical examiner or coroner) vary slightly by jurisdiction . Physicians and advanced practitioners should consult with their local health department to learn of the medical examiner/coroner reporting requirements. These requirements are published in statutes and regulations within local health codes. Additionally, most hospitals have instructions accessible for reporting deaths to the medical examiner/coroner.
A listing of all reportable deaths by state is available from the CDC here.
In general, reportable deaths will include the following, regardless of age or place of death :
●Accidents, suicides, homicides
●Poisoning, drug intoxication
●Disease with potential public health threat (as determined by local health departments)
●Deaths resulting from employment
●Sudden and unexpected deaths not caused by a readily recognized disease
●Death related to medical or surgical complications
●Suspicious and unnatural deaths
●Deaths of individuals in police custody
●Deaths occurring outside of a medical care setting (excluding home hospice deaths without any recent injury, eg, a fall)
●Deaths of persons who are not under the care of a physician (unattended deaths)
Certain terms signify that an injury or intoxication may have contributed to the death. Clinicians using any of the following terms should contact the medical examiner/coroner's office before issuing the death certificate.
Terms related to injury:
Terms related to intoxication:
●Drug or alcohol overdose
●Anaphylaxis (this term may be related to a medication reaction [complication of therapy] or due to a bee sting [injury])
CONSIDERATIONS FOR SPECIAL POPULATIONS — Deaths that occur in these situations or among these patients may have unique considerations for medical providers:
●In the home – Primary care providers may be contacted by a funeral director when a patient dies at home. The medical history and risk factors (eg, smoking, obesity) are considered and a death certificate may be issued. The police will have responded to the scene of death and the medical examiner likely will have been notified and declined further investigation. Those factors should reassure the doctor that suspicious circumstances and trauma have been excluded. The cause of death can be completed remembering the probability standard, more likely than not this patient died of an etiologically specific disease.
●In the hospital – Hospital-based physicians are frequently asked to issue death certificates. They should consider the original reason for admission to the hospital and verify that it was not due to trauma or intoxication. If the hospital course was all for the management of underling medical disease, then the death certificate can be issued with that specific disease entity as the underlying cause of death.
●Following surgery – The certifying surgeon needs to be mindful of the underlying reason for the surgery (eg, abscess due to perforation by colonic diverticulitis). This disease (or injury) is the underlying cause of death. The surgeon also needs to evaluate whether or not the surgical interventions hastened the death (eg, a complication of a gastrostomy tube placed in preparation for laryngeal cancer chemotherapy). Alternatively, if an individual is admitted with a subdural hematoma from a fall and undergoes craniotomy and later dies, that death is the sequelae of the fall, a traumatic injury, and is reportable to the medical examiner/coroner.
●In the emergency department – A death in the emergency department may be due to both natural and/or unnatural causes. The first layer of scrutiny is whether or not an injury or intoxication may have played a role in the death. If so, it must be reported to the medical examiner/coroner. If a recent or remote injury or intoxication did not contribute, then the death is due to a medical condition. The medical history and risk factors are considered in determining the cause of death.
●In skilled nursing facilities – It is critical for the skilled nursing facility death certifier to consider the patient's full medical history. For example, it is not uncommon for an older adult to have sustained a fall with a hip fracture or subdural hemorrhage and then die a few weeks later in a nursing home. In this example, an injury has contributed to the death and the death certificate must be reported to the medical examiner/coroner. In order to invoke an injury on the death certificate, there must be a direct pathophysiologic link between the event and the death that demonstrates the injury a contributed to the death (eg, a fracture causing a pulmonary thromboembolism). There is no time limit between the injury and cause of death, and the interval may extend for years (eg, urosepsis-complicating paraplegia due to a remote gunshot wound of the spine). When in doubt, it is best to consult with the medical examiner/coroner prior to filling out the certificate.
●Pregnant patients – The death of a pregnant or postpartum patient is uncommon. If the death involves a placental abruption and hemorrhage or uterine "rupture" an underlying traumatic injury or cocaine use must be considered. Those scenarios are reportable to the medical examiner/coroner.
●Children – Children die most commonly of acute traumatic, congenital, or oncologic causes. Deaths due to acute or remote trauma or due to suspected neglect are reportable to the medical examiner/coroner.
MEDICAL EXAMINER INVESTIGATIONS — The medical examiner/coroner receives reports of death from medical caregivers (eg, hospitals, nursing homes, hospice) and also from police departments or funeral directors for deaths occurring outside of a medical setting. The reports of death are made based on the statutory requirements outlined above (see 'Deaths reportable to medical examiner/coroner' above). Following the report of death, the medical examiner/coroner will determine the type of investigation that will follow. A forensic pathologist is the medical specialist who performs the autopsy and investigation. Medicolegal death investigators are professionals who assist the medical examiner/coroner by performing scene investigations, triaging cases, obtaining medical records, etc. The medical examiner/coroner also may employ a telecommunications staff to obtain and accession the initial case information during the telephone report of death.
Scene investigation — For a death outside of a medical setting (eg, home, highway, railroad tracks, sidewalk), a representative from the medical examiner/coroner usually will visit the scene to examine the body and look for details pertinent to the death investigation (eg, drug paraphernalia, suicide notes, medication bottles). The body may then be transported to the medical examiner/coroner facility for further examination/autopsy.
Hospital deaths — The medical examiner/coroner telecommunications person and/or medicolegal death investigator will acquire all the demographic information and details of hospital course, and they may ask for additional medical records. The medical examiner/coroner will determine if the body needs to be transported to their facility for an autopsy. Sometimes in delayed traumatic deaths, if the hospital staff adequately document the injuries, and there is no suggestion of criminality, the medical examiner/coroner may issue the death certificate and the body can be released to the funeral home. The medical examiner/coroner will usually give the reported death a unique medical examiner/coroner case number.
Autopsy — An autopsy is an examination of the body after death. It includes an external examination looking for signs of injury or disease, an in situ examination of the organs and the state of the body cavities, and then an organ by organ gross and even microscopic examination looking for disease and injury [6,26,35]. Not all medical examiner/coroner deaths will undergo an autopsy. Some may have only an external examination or medical record review depending on the history and circumstances. Autopsy reports are available to family members, treating physicians and law enforcement agents.
Toxicology — Specimens are routinely collected for toxicological testing. The typical samples are peripheral blood, heart blood, vitreous fluid, urine, gastric contents, brain, and liver tissue. If a hospitalized patient dies several days after admission, the medical examiner/coroner will contact the hospital lab and request that the original fluid samples be put on hold. Those samples are the most relevant to investigation to determine if the patient was intoxicated at the time of injury or if the death was caused by intoxication [36-40].
Infant deaths — Sudden unexpected infant deaths must be reported to the medical examiner/coroner. These comprehensive medicolegal investigations involve an examination of the infant at the hospital, a review of pediatric records and the home environment, an interview with the family and a reenactment of the circumstances under which the infant was last known alive and found, and a complete autopsy with microbiology and toxicology testing, and special procedures as needed. Frequently, the sleep environment is a factor in the cause of such deaths, so the scene examination is imperative . Issues related to sudden infant death are also discussed elsewhere. (See "Sudden unexpected infant death including SIDS: Initial management", section on 'Case investigation'.)
In-custody deaths (police/prison) — These are reportable to the medical examiner/coroner even if injury is not evident or suspected .
Organ donors — The medical examiner/coroner is contacted by tissue and organ procurement organizations prior to donation for certain deaths that fall under the jurisdiction of the medical examiner/coroner (eg, a person with a gunshot wound of the head whose heart is still beating with the assistance of life support). The medical examiner/coroner may restrict certain donations if it interferes with their ability to investigate the death in light of later potential legal proceedings.
BURIAL PERMIT/CREMATION — The family of the decedent selects the disposition of the remains and works with the funeral director to facilitate their wishes. If an in-state burial is selected, then a burial permit is issued by the governmental registrar of the death certificate. If an out-of-state disposition is selected, then a transit permit may be required. There are many parts of the country where reciprocity is given to funeral directors working within a region.
In many parts of the United States, if cremation is requested then approval for cremation by the medical examiner/coroner may be required [7,43-46]. This is the last chance for an investigation of the body to happen prior to the body being irreversibly altered to ashes. This investigation typically involves a review of the completed death certificate with a more in-depth investigation depending on the cause and circumstances of death.
The family also may decide to send the body to another country for final disposition. The transportation of remains must conform to various standards put forth by the receiving country. The funeral directors research these requirements and prepare the body as needed. Oftentimes a letter declaring whether or not a communicable disease caused the death is required to accompany the body and documents, completed by the person who certified the death. Less frequent dispositions include anatomic gift of body to a medical school or even burial at sea.
Funeral directors receive formal training during school and for maintenance of licensure that keeps them current with regulations on embalming and postmortem preparation of the body.
FLOW OF INFORMATION — Upon completion and registration of a death certificate, the next of kin will need copies of the official death record as proof of death. This allows for leases and utilities to be cancelled, bank accounts to be closed, and other logistical issues to be resolved.
The death certificate is registered within the town/city/county of death. This registration results in the notification of Social Security Administration and the initiation of the process of coupling the death record to the birth record. The state receives the death certificate data and uses it for population statistics and disease/injury mortality data. The state shares the data with the National Center for Health Statistics (NCHS)/US Centers for Disease Control and Prevention (CDC) and the cause of death data are coded. National mortality statistics are then derived.
Rules regarding release of information vary by jurisdiction. In some states, the death certificate is a public record. Usually, this information is available to those with a "legitimate interest" (eg, law enforcement, insurance company). The death certificate is released by the registrar/vital records clerk in the jurisdiction of death and they will inquire as to the relationship of the individual seeking the data; a fee is generally required.
PUBLIC HEALTH MONITORING
Coding/abstraction — The US Centers for Disease Control and Prevention (CDC) and National Center for Health Statistics (NCHS) have established various programs to investigate subsets of deaths . The National Violent Death Registry System catalogs certain unnatural deaths and abstracts additional case-related detail [47-49]. The State Unintentional Drug Overdose Reporting System is a similar CDC database that tracks accidental drug intoxication deaths and other case-related detail . Individual states also have databases and methods for using death certificate data for prevention strategies.
Examples of how death certificate data are used for harm reduction — The use and benefits of death certificates goes beyond a vital records function . Research directions and funding may be driven by increases and decreases in mortality by various diseases and injuries. Examples include:
●Transportation deaths (eg, seatbelts, airbags, intoxications) [50-59]
●Infant deaths ("Back to Sleep"/"Don’t Shake" campaigns) [60-64]
●Recalls on medical devices and medications (US Food and Drug Administration MedWatch) 
●Epidemiological clustering of disease and unnatural deaths (eg, opioid crisis) [48,66-74]
●Consumer Product Safety Commission recalls on faulty consumer products (eg, faulty cribs) 
●Occupational Safety and Health Administration/Department of Labor – Work-related deaths (eg, falls, electrocutions) [76,77]
●Maternal mortality [78-89]
Opioid fatalities/harm reduction — By the precise listing of drugs on the death certificate, medical examiners/coroners have helped demonstrate the evolution of the opioid crisis from prescription medications, to heroin, and then fentanyl. The data can be used to track trends in communities and involve local outreach groups. Additionally, there is a program through the CDC to track suspected overdoses in order to act more quickly with deterrents, rescue medications, substance use support organizations, and awareness [68,74,90-92].
●Importance – Death certificate completion, and appropriate medical examiner involvement after death are important components of patient care. Death certificate information is used by government and other agencies for monitoring morbidity and mortality, scientific study, legislative change, research and funding prioritization, public health strategies and public safety initiatives. (See 'Purpose of the death certificate' above and 'Public health monitoring' above.)
●Medical information – The medical information on a death certificate includes the pronouncement of death as well as the medical certification of the cause of death, which has two components: the cause of death (Part 1) and contributing conditions (Part 2) (form 1). (See 'Pronouncement' above and 'Medical certification of death' above and 'Contributing conditions' above.)
•Documenting the cause of death – The death certificate documents the cause of death by potentially describing three components: the mechanism, the immediate cause, and the underlying cause. The underlying cause is the only one that provides information on the condition responsible for the death and is the only one that is required. When documented, the three conditions should have a causal relationship to one another within a single disease process or continuum, and this description is called a "cause of death statement." Several examples of proper documentation for different patient scenarios are provided in the table (table 1). (See 'Documenting the cause of death' above.)
•COVID-19 documentation – The US Centers for Disease Control and Prevention (CDC) provides information on how to certify these deaths. (See 'COVID-19 documentation' above.)
•Errors – Errors on death certificates are common. (See 'Common mistakes/misconceptions' above.)
●Reporting to the medical examiner/coroner – Deaths that are reportable to the governmental medicolegal death investigation authority (medical examiner/coroner) vary slightly by jurisdiction. Following the report of death, the medical examiner/coroner will determine the type of investigation that will follow. Physicians and advanced practitioners should consult with their local health department to learn of the medical examiner/coroner reporting requirements. (See 'Deaths reportable to medical examiner/coroner' above.)
●Special populations – Deaths that occur in certain situations (eg, in the home, hospital, emergency department, skilled nursing facilities, or after surgery) or among certain patients (eg, pregnant persons or children) may have unique considerations for medical providers. (See 'Considerations for special populations' above.)
3 : Conditions other than underlying cause of death listed on death certificates provide additional useful information for epidemiologic research.
6 : The "value-added" forensic autopsy: Public health, other uses, and relevance to forensic pathology's future
8 : The role of medical examiners and coroners in public health surveillance and epidemiologic research.
10 : Use and accuracy of state death certificates for classification of sudden cardiac deaths in high-risk populations.
15 : Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.
17 : Severe Acute Respiratory Syndrome Coronavirus 2 Surveillance in Decedents in a Large, Urban Medical Examiner's Office.
22 : Validation of death certificate diagnosis of out-of-hospital coronary heart disease deaths in Olmsted County, Minnesota.
25 : Accuracy of Death Certificates and Assessment of Factors for Misclassification of Underlying Cause of Death.
29 : Discrepancies in death certificates, public health registries, and judicial determinations in Italy.
41 : Infant death scene investigation and the assessment of potential risk factors for asphyxia: a review of 209 sudden unexpected infant deaths.
42 : National Association of Medical Examiners Position Paper: Recommendations for the Definition, Investigation, Postmortem Examination, and Reporting of Deaths in Custody.
46 : Death investigation in the United States, 1990: A survey of statutes, systems, and educational requirements
49 : Opioid Overdose Deaths with Buprenorphine Detected in Postmortem Toxicology: a Retrospective Analysis.
50 : Motor vehicle occupants, neck injuries, and seat belt utilization: a 5-year study of fatalities in New York City.
52 : The characteristics of all-terrain vehicle (ATV)-related deaths: A forensic autopsy data-based study.
53 : Fatally injured pedestrians and bicyclists in the United States with high blood alcohol concentrations.
55 : A review of alcohol-impaired driving: the role of blood alcohol concentration and complexity of the driving task.
58 : Reductions in deaths in frontal crashes among right front passengers in vehicles equipped with passenger air bags.
61 : Recent Iowa trends in sudden unexpected infant deaths: the importance of public health collaboration with medical examiners' offices.
63 : Epidemiologic features of 1,134 sudden, unexpected infant deaths. A study in the Greater Cleveland Area from 1956 to 1965.
65 : Introducing MEDWatch. A new approach to reporting medication and device adverse effects and product problems.
91 : Death certification and investigation of opioid intoxication fatalities: The medical examiner perspective