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16. Facility Name (if not institution, give street address): .............................................................................. 29
17. Informant's Name & Relationship To decedent ............................................................................................ 30
18. Mailing Address of Informant (Street and Number, City, State, and Zip Code) ............................... 30
19. Method of Disposition ............................................................................................................................................. 30
20. Signature of Funeral Director or Person Acting as Such ........................................................................... 31
21. Unknown, Section, Block, Lot, Space ................................................................................................................. 31
22. Place of Disposition (Name of Cemetery, Crematory, or Other Place) ................................................ 31
23. Location (City/Town, and State) ......................................................................................................................... 32
24. Name of Funeral Facility ........................................................................................................................................ 32
25. Complete Address of Funeral Facility (Street and Number, City, State, Zip Code): ....................... 32
26. Certifier.......................................................................................................................................................................... 32
27. Signature of Certifier ................................................................................................................................................ 32
28. Date Signed (Month Day Year) ............................................................................................................................ 32
29. License Number ......................................................................................................................................................... 33
30. Time of Death (Actual or Presumed) ................................................................................................................ 33
31. Printed Name, Address of Certifier (Street and Number, City, State, Zip Code) ............................. 33
32. Title of Certifier: ......................................................................................................................................................... 33
33. Cause of Death ............................................................................................................................................................ 33
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: .................................................................................................................................................... 34
Part 2. Enter Other Significant Conditions Contributing To Death But Not Resulting In The
Underlying Cause Given In Part 1 ......................................................................................................................... 35
34. Was An Autopsy Performed?: .............................................................................................................................. 35
35. Were Autopsy Findings Available to Completion of Cause of Death? .................................................. 35
36. Manner of Death ........................................................................................................................................................ 35
37. Did Tobacco Use Contribute to Death? ............................................................................................................. 36
38. If Female: ...................................................................................................................................................................... 36
Items 39 through 41- Injury Information:.............................................................................................................. 36
39. If Transportation Injury, Specify: ................................................................................................................... 36
40a. Date of Injury (Mo/Day/YYYY): ................................................................................................................... 37
40b. Time of Injury: ..................................................................................................................................................... 37
40c. Injury at Work? ................................................................................................................................................... 37
40d. Place of Injury (e.g. Decedent's Home, Construction Site, Restaurant, Wooded Area): ....... 38
40e. Location (Street and Number or Rural Route, City or Town, State): ............................................ 38