A death certificate is the official document that declares a person is dead. Death certificates serve two purposes: they prevent murder cover-ups by restricting those who can complete them for non-natural deaths to trained officials who generally have great latitude on whom they perform postmortem examinations, and they provide public health statistics. Death registration was first required in the United Kingdom in 1874. Before then, it was not even necessary for a physician to view the corpse. In the United States, Great Britain, and most industrialized countries, physicians must now sign a death certificate listing the presumed cause of death. Otherwise, a medical examiner (forensic pathologist) will intervene with an autopsy to determine the cause of death in the event that a case requires police investigation.
People use death certificates in multiple ways. Survivors need death certificates to obtain burial permits, make life insurance claims, settle estates, and obtain death benefits. Public health departments look for patterns that may signal specific health problems, such as clusters of cancers that may reveal unknown toxic waste dumps.
There are three types of death certificates in the United States, including a standard certificate, one for medical/legal cases, and one for fetal or stillborn deaths. All but two states require a death certificate for fetal deaths. However, the majority of states only require a certificate if the fetus was past twenty weeks of gestation. All are based on the international form agreed to in 1948 (modified for clarity in the United States in the 1990s). This form lists the immediate cause of death (e.g., heart attack, stroke), conditions that resulted in the immediate cause of death (e.g., gunshot wound to the chest), and other significant medical conditions (e.g., hypertension, atherosclerotic coronary artery disease, or diabetes). The form also includes a place to record whether an autopsy was performed and the manner of death such as natural, accident, suicide, homicide, could not be determined, or pending investigation.
Death certificates are occasionally used to fake a person's death for insurance fraud and to evade law enforcement officials or irate relatives. "Official" Los Angeles County death certificates, for example, were readily available in the mid-1990s for between $500 and $1,000 each. For fraudulent purposes, people have often used death certificates from remote nations and from countries in turmoil.
To complete death certificates, funeral directors first insert the decedent's personal information, including the name, sex, date of death, social security number, age at last birthday, birth date, birthplace, race, current address, usual occupation, educational history, service in the U.S. armed forces, site and address of death, marital status, name of any surviving spouse, parents' names, and informant's name and address. They also include the method and site of body disposition (burial, cremation, donation, or other) and sign the form. The responsible physician must then complete, with or without using an autopsy, his or her sections of the certificate. These include the immediate cause(s) of death; other significant conditions contributing to the death; the manner of death; the date, time, place, and mechanism of any injury; the time of death; the date the death was pronounced; whether the medical examiner was notified; and his or her signature. The death certificate then passes to the responsible local and state government offices, where, based on that document, a burial permit is issued. The death certificate, or at least the information it contains, then goes to the state's bureau of vital statistics and from there to the United States Center for Health Statistics.
Funeral directors often struggle to obtain a physician's signature on a death certificate. In an age of managed-care HMOs and multispecialty clinics, they must not only locate the busy practitioner for a signature, but also identify the correct physician. Survivors cannot bury or otherwise dispose of a corpse until a licensed physician signs a permanent death certificate or a medical examiner signs a temporary death certificate. Medical examiners (or coroners) list the cause of death as "pending" until further laboratory tests determine the actual cause of death. Except in unusual cases, disposition of the remains need not wait for the final autopsy report, which may take weeks to complete.
After the death certificate has been signed, local authorities usually issue a certificate of disposition of remains, also known as a burial or cremation permit. Crematories and cemeteries require this form before they will cremate or bury a body. In some jurisdictions, the form is combined with a transportation permit that allows the movement or shipment of a body. The need for regulation of death certificates became evident in 1866. When New York City first installed an independent Board of Health in March 1866, city police inspected the offices of F. I. A. Boole, the former city inspector. According to the New York Times, police found a large number of unnumbered burial permits, which Boole had already signed. They claimed that Boole had been selling these to murderers who used them to legally bury their victims' bodies.
Public health policies depend heavily on the mortality data from death certificates because they are the only source of information about the causes of death and illnesses preceding death. For example, when Italy's Del Lazio Epidemiological Observatory reviewed 44,000 death certificates, it found that most diseases divided neatly along class lines. The poor died of lung tumors, cirrhosis of the liver, respiratory diseases, and "preventable deaths" (appendicitis, childbirth complications, juvenile hypertension, and acute respiratory infections). Well-to-do women had higher rates of breast cancer. It also found that the incidence of heart disease, strokes, and some cancers did not vary with income level. These findings have had a significant impact on how the Italian government funds its health care system.
Yet the accuracy of death certificates in the United States is questionable, with up to 29 percent of physicians erring both as to the cause of death and the deceased's age. About the same number incorrectly state whether an autopsy was done. Less significant discrepancies occur in listing the deceased's marital status, race, and place of birth. Death certificates of minority groups have the most errors. Only about 12 percent of U.S. physicians receive training in completing death certificates, and less than two-thirds of them do it correctly. Several do not appear to believe that completing death certificates accurately is very important.
Many certificates are meaningless because physicians complete them without knowing the real cause of death. Listing "cardiopulmonary arrest" signifies nothing—everyone's heart and lungs eventually stop. The important point is why? An autopsy is often needed to answer this question. Occasionally, autopsy, pathology, or forensic findings appear after a death certificate has been completed. If it is within three years of the death in many jurisdictions, the original physician-signer need only complete an amended certificate to correct the record.
Disguising deaths from alcoholism, AIDS, and other stigmatizing causes of death on death certificates is widespread. This practice appears to be more common where medical examiners' autopsy reports are part of the public record. For this reason, some states may eliminate the cause of death from publicly recorded death certificates.
Physicians obscure information on some death certificates to protect a family's reputation or income, with listings such as "pneumonia" for an AIDS death or "accidental" for a suicide. Even before the AIDS epidemic, one researcher found that in San Francisco, California, socially unacceptable causes of death frequently were misreported—the most common being alcoholic cirrhosis of the liver, alcoholism, syphilis, homicide, and suicide.
A similar problem with the accuracy of death certificates has been reported in Great Britain. The Royal College of Physicians of London claims that 20 percent of British death certificates incorrectly list the cause of death. In one instance, for example, the number of reported suicides at Beachy Head (a popular spot at which to commit suicide by jumping into the sea) diminished by one-third simply with a change in coroners.
Physicians who complete death certificates in good faith are not liable to criminal action, even if the cause of death is later found to be different from that recorded. Fraudulent completion to obscure a crime or to defraud an insurance company, however, is a felony.
Occasionally, fake death certificates appropriate real people's identities. Such false death certificates are especially distasteful to victims of this fraud who are still alive and whose "death" causes officials to freeze their assets, cancel credit, revoke licenses, and generally disrupt their lives.
Deaths that occur aboard ships are handled very differently. For example, British captains register any crew or passenger death in the ship's log, the information approximating that on a death certificate. On arrival at a British port, the captain must report the death to harbor authorities, who then investigate the circumstances.
Death certificates and other standard legal papers surrounding death normally cost between $1 and $5 each. The funeral director usually obtains these forms and itemizes their costs on the bill. In cases where a body must be shipped to a non-English-speaking country, the forms must often be translated at an additional cost.
Hanzlick Randy, and H. Gib Parrish. "The Failure of Death Certificates to Record the Performance of Autopsies." Journal of the American Medical Association 269, no. 1 (1993):47.
Kircher, Tobia, Judith Nelson, and Harold Burdo. "The Autopsy As a Measure of Accuracy of the Death Certificate." New England Journal of Medicine 310, no. 20 (1985):1263–1269.
Messite Jacqueline, and Steven D. Stellman. "Accuracy of Death Certificate Completion." Journal of the American Medical Association 275, no. 10 (1996):794–796.
Wallace, Robert B., and Robert F. Woolson. Epidemiologic Study of the Elderly. New York: Oxford University Press, 1992.
KENNETH V. ISERSON