National Vital Statistics System

Possible Solutions to Common Problems in Death Certification

National Center for Health Statistics, January 1997
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services


A death certificate is a permanent record of an individual’s death. One purpose of the death certificate is to obtain a simple description of the sequence or process leading to death rather than a record describing all medical conditions present at death.

Causes of death on the death certificate represent a medical opinion that might vary among individual physicians. In signing the death certificate, the physician, medical examiner, or coroner certifies that, in his/her medical opinion, the individual died from the reported causes of death. The certifier’s opinion and confidence in that opinion are based upon his/her training, knowledge of medicine, available medical history, symptoms, diagnostic tests, and available autopsy results for the decedent. Even if extensive information is available to the certifier, causes of death may be difficult to determine, so the certifier may indicate uncertainty by qualifying the causes on the death certificate.

Cause-of-death data is important for surveillance, research, design of public health and medical interventions, and funding decisions for research and development. While the death certificate is a legal document used for legal, family, and insurance purposes, it may not be the only record used, because, in some cases, the death certificate may only be admissible as proof of death. The following provides suggestions, largely from Hanzlick (1994), for handling situations where cause of death is difficult to certify.



Often several acceptable ways of writing a cause-of-death statement exist. Optimally, a certifier will be able to provide a simple description of the process leading to death that is etiologically clear and to be confident that this is the correct sequence of causes. However, realistically, description of the process is sometimes difficult because the certifier is not certain.

In this case, the certifier should think through the causes about which he/she is confident and what possible etiologies could have resulted in these conditions. The certifier should select the causes that are suspected to have been involved and use words such as “probable” or “presumed” to indicate that the description provided is not completely certain. If the initiating condition reported on the death certificate could have arisen from a pre-existing condition but the certifier cannot determine the etiology, he/she should state that the etiology is unknown, undetermined, or unspecified, so it is clear that the certifier did not have enough information to provide even a qualified etiology.


The Elderly

When preparing a cause-of-death statement for an elderly decedent, the causes should present a clear and distinct etiological sequence, if possible. Causes of death on the death certificate should not include terms such as senescence, old age, infirmity, and advanced age because they have little value for public health or medical research. Age is recorded elsewhere on the death certificate. When malnutrition is involved, the certifier should consider if other medical conditions could have led to malnutrition.

When a number of conditions or multiple organ/system failure resulted in death, the physician, medical examiner, or coroner should choose a single sequence to describe the process leading to death and list the other conditions in Part II of the certification section. “Multiple system failure” could be included as an “other significant condition” but also specify the systems involved. In other instances, conditions listed in Part II of the death certificate may include causes that resulted from the underlying cause but did not fit into the sequence resulting in death.

If the certifier cannot determine a descriptive sequence of causes of death despite carefully considering all information available and circumstances of death did not warrant investigation by the medical examiner or coroner, death may be reported as “unspecified natural causes.” If any potentially lethal medical conditions are known but cannot be cited as part of the sequence leading to death, they should be listed as other significant conditions.


Infant Deaths

Maternal conditions may have initiated or affected the sequence that resulted in an infant death. These maternal conditions should be reported in the cause-of-death statement in addition to the infant causes.

When Sudden infant death syndrome (SIDS) is suspected, a complete investigation should be conducted, typically by a medical examiner. If the infant is under 1 year of age, no cause of death is determined after scene investigation, clinical history is reviewed, and a complete autopsy is performed, then the death can be reported as (SIDS). If the investigation is not complete, the death may be reported as presumed to be (SIDS).


Avoid Ambiguity

Most certifiers will find themselves, at some point, in the circumstance in which they are unable to provide a simple description of the process of death. In this situation, the certifier should try to provide a clear sequence, qualify the causes about which he/she is uncertain, and be able to explain the certification chosen.

When processes such as the following are reported, additional information about the etiology should be reported if possible:

Acute myocardial infarction Congestive heart failure Myocardial infarction
Arrhythmia Cardiomyopathy Shock
Atrial fibrillation Dysrhythmia Ventricular fibrillation
Cardiac arrest Heart failure Ventricular tachycardia
Cardiac dysrhythmia Hypotension
Central Nervous System
Altered mental status Cerebral edema Open (or closed) head injury
Anoxic encephalopathy Dementia (when not otherwise specified) Seizures
Brain injury Epidural hematoma Subdural hematoma
Brain stem herniation Increased intracranial pressure Subarachnoid hemorrhage
Cerebrovascular accident Intracranial Hemorrhage Uncal herniation
Cerebellar tonsillar herniation Metabolic encephalopathy
Aspiration Pneumonia Pulmonary insufficiency
Pleural effusions Pulmonary embolism Pulmonary edema
Biliary obstruction Diarrhea Hepatic failure
Bowel obstruction End-stage liver disease Hepatorenal syndrome
Cirrhosis Gastrointestinal hemorrhage Perforated gallbladder
Blood, Renal, Immune
Coagulopathy Hepatorenal syndrome Renal failure
Disseminated intravascular coagulopathy Immunosuppression Thrombocytopenia
End-stage renal disease Pancytopenia Urinary tract infection
Not System-Oriented
Abdominal hemorrhage Decubiti Hyponatremia
Ascites Dehydration Multi-organ failure
Anoxia Exsanguination Necrotizing soft-tissue infection
Bacteremia Failure to thrive Peritonitis
Bedridden Gangrene Sepsis
Carcinogenesis Hemothorax Septic shock
Carcinomatosis Hyperglycemia Shock
Chronic bedridden state Hyperkalemia Volume depletion

(Hanzlick pp. 106-7)

If the certifier is unable to determine the etiology of a process such as those shown above, the process must be qualified as being of an unknown, undetermined, probable, presumed, or unspecified etiology so it is clear that a distinct etiology was not inadvertently or carelessly omitted.

The following conditions and types of death might seem to be specific but when the medical history is examined further may be found to be complications of an injury or poisoning (possibly occurring long ago):

  • Subdural hematoma
  • Epidural hematoma
  • Subarachnoid hemorrhage
  • Fracture
  • Pulmonary emboli
  • Thermal burns/chemical burns
  • Sepsis
  • Hyperthermia
  • Hypothermia
  • Hip fracture
  • Seizure disorder
  • Drug or alcohol overdose/drug or alcohol abuse

(Hanzlick p. 68)

Is it possible that the underlying cause of death was the result of an injury or poisoning? If it might be, check with the medical examiner/coroner to find out if the death should be reported to him/her.

When indicating neoplasms as a cause of death indicate the following:

  1. primary site or that the primary site is unknown,
  2. benign or malignant,
  3. cell type or that the cell type is unknown,
  4. grade of a neoplasm, and
  5. part or lobe of an organ affected. For example, a well-differentiated squamous cell carcinoma, lung, left upper lobe (Hanzlick p. 58).


Medical Examiner or Coroner

The medical examiner/coroner investigates deaths that are unexpected, unexplained, or if an injury or poisoning was involved. State laws often provide guidelines for when a medical examiner/coroner must be notified. In the case of deaths known or suspected to have resulted from injury or poisoning, report the death to the medical examiner/coroner as required by State law. The medical examiner/coroner will either complete the cause-of-death section of the death certificate or waive that responsibility. If the medical examiner/coroner does not accept the case, then the certifier will need to complete the cause-of-death section.


References and Sources

Hanzlick R, ed. 1994. The Medical Cause of Death Manual. Northfield, IL: College of American Pathologists.

National Center for Health Statistics. 2003. Physicians’ Handbook on Medical Certification of Death [PDF – 1.4 MB]. Hyattsville, MD: Public Health Service.

National Center for Health Statistics. 1989. Report of the Workshop on Improving Cause-of-Death Statistics. Hyattsville, MD: Public Health Service.

National Center for Health Statistics. 1991. Report of the Second Workshop on Improving Cause-of-Death Statistics. Hyattsville, MD: Public Health Service.

National Center for Health Statistics. 1999. Technical Appendix. Vital Statistics of the United States, 1995, vol II, mortality, part A. Washington: Public Health Service.

Additional Information Can Also be Found at:
National Association of Medical Examiners (N.A.M.E.)