The Missouri Certificate of Death form is an official document used to record the details surrounding an individual's death. This form collects essential information such as the decedent's legal name, date of birth, and cause of death, which are vital for legal and statistical purposes. Accurate completion of this form is crucial for the proper handling of estate matters and public health records; to begin this process, click the button below to fill out the form.
The Missouri Certificate of Death form is an essential document that serves multiple purposes following the death of an individual. It captures critical information about the deceased, including their legal name, date of birth, and social security number. The form also requires details about the decedent's sex, marital status, and residence at the time of death. In addition to identifying the individual, the form provides space for recording the date, time, and place of death, as well as the manner of death—whether it was natural, accidental, or due to other circumstances. The cause of death must be clearly stated, detailing the chain of events leading to the fatal outcome. This includes information on any significant contributing conditions. Furthermore, the form collects data on the decedent's family, such as the names of parents and the surviving spouse, which can be important for legal and estate matters. Completing this form accurately is crucial, as it not only serves as a record for public health but also plays a vital role in the grieving process and the legal affairs that follow a death.
STATE FILE NUMBER
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
124 -
VS 300 MO 580-2211 (1-10)
CERTIFICATE OF DEATH
1. DECEDENTʼS LEGAL NAME (Include AKAʼs if any) (First, Middle, Last, Suffix)
2. SEX
3.IF FEMALE, LAST NAME PRIOR TO FIRST
3.MARRIAGE
4.ACTUAL OR PRESUMED
4.DATE OF DEATH (Month, Day, Year)
5. SOCIAL SECURITY NUMBER
6a. AGE - Last
6a. Birthday (Years)
6b. UNDER 1 YEAR
6c. UNDER 1 DAY
MONTHS
DAYS
HOURS
MINUTES
7. DATE OF BIRTH (Month, Day, Year)
8. BIRTHPLACE (City and State or Foreign Country)
9a. RESIDENCE (COUNTRY)
(STATE, TERRITORY or PROVINCE)
9b. COUNTY
9c. CITY, TOWN, OR LOCATION
9d. STREETAND NUMBER
9e. APARTMENT NO.
9f. ZIP CODE
9g. INSIDE CITY LIMITS?
Yes
No
10. WAS DECEDENT EVER IN U.S.
11. MARITAL STATUS AT TIME OF DEATH
12. SURVIVING SPOUSEʼS NAME (If wife, give name prior to first marriage.)
10. ARMED FORCES?
Married
Married, but separated
Widowed
Divorced
Never Married
Unknown
13. FATHERʼS NAME (First, Middle, Last, Suffix)
14. MOTHERʼS NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last, Suffix)
15a. INFORMANTʼS NAME (First, Middle, Last, Suffix)
15b. RELATIONSHIP TO DECEDENT
15c. MAILING ADDRESS (Street and Number, City, State, ZIP Code)
16. PLACE OF DEATH (Check only one: see instructions.)
IF DEATH OCCURRED IN A HOSPITAL
Inpatient
Emergency Room/Outpatient
DOA
IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL
Hospice Facility
Nursing Home/Long Term Care Facility
Decedentʼs Home
Other (Specify)
17. FACILITY NAME (If not institution, give street and number)
18. CITY OR TOWN, STATE AND ZIP CODE
19. COUNTY OF DEATH
20a. METHOD OF DISPOSITION
Burial
Cremation
Donation
Entombment
Removal from State
20b. DATE OF DISPOSITION
(Month, Day, Year)
21. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)
22. LOCATION (City or Town, State)
23. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
24.SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER PERSON
24.ACTING AS SUCH
�
25.FUNERAL ESTABLISHMENT
25.LICENSE NUMBER
26. ACTUAL OR PRESUMED TIME OF DEATH
M
27. WAS MEDICAL EXAMINER/CORONER CONTACTED?
CAUSE OF DEATH (See instructions and examples in handbook)
28.PART I. 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 NOTABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
IMMEDIATE CAUSE (Final
disease or condition
➔ a.
resulting in death)
Due to (or as a consequence of):
Sequentially list conditions, if
b.
any, leading to the cause listed
on line a. Enter the UNDERLY-
ING CAUSE (disease or injury
that initiated the events resulting
c.
in death) LAST.
d.
Approximate interval : Onset to Death
PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I.
29. WAS AN AUTOPSY PERFORMED?
30. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH?
31. DID TOBACCO USE CONTRIBUTE TO DEATH?
32. IF FEMALE
33. MANNER OF DEATH
Not pregnant within past year
Natural
Homicide
Pregnant at time of death
Accident
Pending investigation
Probably
Not pregnant, but pregnant within 42 days of death
Suicide
Could not be determined
Not pregnant, but pregnant 43 days to 1 year before death
Unknown if pregnant within the past year
34. DATE OF INJURY (Month, Day, Year) (Spell Month)
35. TIME OF INJURY
36. PLACE OF INJURY (e.g., decedentʼs home; construction site; restaurant; wooded area)
37. INJURYAT WORK?
38a. LOCATION OF INJURY - STATE
38b. COUNTY
38c. CITY OR TOWN
38d. STREETAND NUMBER
38e. ZIP CODE
39.DESCRIBE HOW INJURY OCCURRED
41.CERTIFIER (CHECK ONLY ONE)
40. IF TRANSPORTATION ACCIDENT (SPECIFY)
Driver/Operator
Passenger
Pedestrian
Certifying Physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
Medical Examiner/Coroner - 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 �
42. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 28)
43. TITLE OF CERTIFIER
44. CERTIFIER MO LICENSE NUMBER
45. CERTIFIER NPI NUMBER
46. DATE CERTIFIED (Month, Day, Year)
47. REGISTRARʼS SIGNATURE
48. FOR REGISTRAR ONLY - DATE FILED (Month, Day, Year)
49. DECEDENTʼS EDUCATION
50. DECEDENT OF HISPANIC ORIGIN?
51. DECEDENTʼS RACE
(Check the box that best describes the highest degree or level of school
(Check the box that best describes whether the
(Check one or more races to indicate what the decedent considered himself or herself to be.)
completed at time of death.)
decedent is Spanish/Hispanic/Latino. Check the
White
Other Asian
“No” box if decedent is not Spanish/Hispanic/Latino.)
8th grade or less
Black or African American
(Specify) __________________________
No, not Spanish/Hispanic/Latino
9th - 12th grade; no diploma
American Indian or Alaska Native
Native Hawaiian
Yes, Mexican, Mexican American,
High school graduate or GED completed
(Name of the enrolled or principal tribe)
Guamanian or Chamorro
Chicano
Some college credit, but no degree
____________________________
Samoan
Yes, Puerto Rican
Associate degree (e.g., AA, AS)
Asian Indian
Other Pacific Islander
Yes, Cuban
Bachelorʼs degree (e.g., BA, AB, BS)
Chinese
Yes, other Spanish/Hispanic/Latino
Masterʼs degree (e.g., MA, MS, MEng, MeD, MSW, MBA)
Filipino
Other
(Specify) ________________________
Doctorate (e.g., PhD, EdD) or professional
Japanese
degree (e.g., MD, DDS, DVM, LLB, JD)
________________________________
Korean
Vietnamese
52. DECEDENTʼS USUAL OCCUPATION (INDICATE TYPE OF WORK DONE DURING MOST OF WORKING LIFE. DO NOT USE
53. KIND OF BUSINESS/INDUSTRY
52. “RETIRED”.)
EMBALMED
NOT EMBALMED
STATEMENT BY LICENSED EMBALMER
I hereby certify that the deceased named above was embalmed by me, ________________________________________________________________________________________
(Name and Licensee Number)
or by student _________________________________________________________________ on __________________________________ working under my personal supervision.
(Name and Licensee Number)(Date)
____________________________________________________
City or Town
State
NOTE: Failure to comply with embalming requirements constitutes grounds for revocation of license.
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