Blank Missouri Certificate Of Death Form

Detailed Steps for Filling Out Missouri Certificate Of Death

Completing the Missouri Certificate of Death form is a necessary step following a death. This form requires accurate information about the deceased and the circumstances surrounding their death. The following steps will guide you through the process of filling out this important document.

1. Decedent's Legal Name: Enter the full legal name of the deceased, including any known aliases.
2. Sex: Indicate the sex of the decedent.
3. Last Name Prior to First Marriage: If the decedent is female, provide her last name before her first marriage.
4. Actual or Presumed: Specify whether the date of death is actual or presumed.
5. Date of Death: Fill in the date of death in the format of month, day, and year.
6. Social Security Number: Provide the decedent's Social Security number.
7. Age: Enter the age of the decedent at the time of death, including their last birthday.
8. Date of Birth: Record the decedent's date of birth.
9. Birthplace: Indicate the city and state or foreign country of birth.
10. Residence: Fill in the complete residence information, including country, state, county, city, street address, apartment number, and ZIP code.
11. Inside City Limits: Check "Yes" or "No" to indicate if the residence is within city limits.
12. U.S. Armed Forces: Indicate whether the decedent was ever in the U.S. Armed Forces.
13. Marital Status: Specify the marital status of the decedent at the time of death.
14. Surviving Spouse's Name: If applicable, provide the name of the surviving spouse, including their name prior to first marriage.
15. Father's Name: Enter the full name of the decedent's father.
16. Mother's Name: Provide the mother's name prior to her first marriage.
17. Informant's Name: Fill in the name of the informant, who is the person providing the information.
18. Relationship to Decedent: Specify the informant's relationship to the decedent.
19. Mailing Address: Record the mailing address of the informant.
20. Place of Death: Check the appropriate box indicating where the death occurred.
21. Facility Name: If applicable, provide the name of the facility where the death occurred.
22. City or Town, State, and ZIP Code: Fill in the location of the death.
23. County of Death: Indicate the county where the death occurred.
24. Method of Disposition: Select the method of disposition (e.g., burial, cremation).
25. Date of Disposition: Enter the date of disposition.
26. Place of Disposition: Provide the name of the cemetery, crematory, or other place of disposition.
27. Location: Fill in the city or town and state of the place of disposition.
28. Name and Address of Funeral Facility: Enter the complete name and address of the funeral facility.
29. Signature of Funeral Service Licensee: The funeral service licensee or another authorized person must sign here.
30. Funeral Establishment: Provide the name of the funeral establishment.
31. License Number: Enter the license number of the funeral establishment.
32. Actual or Presumed Time of Death: Record the time of death.
33. Medical Examiner/Coroner Contacted: Indicate whether the medical examiner or coroner was contacted.
34. Cause of Death: Complete the cause of death section as instructed, detailing the chain of events leading to death.
35. Autopsy Performed: Indicate whether an autopsy was performed.
36. Autopsy Findings Available: Specify if the autopsy findings were available to complete the cause of death.
37. Tobacco Use Contributed to Death: Indicate whether tobacco use contributed to the death.
38. Manner of Death: Check the box that best describes the manner of death.
39. Date of Injury: If applicable, enter the date of injury.
40. Time of Injury: Record the time of injury.
41. Place of Injury: Describe where the injury occurred.
42. Injury at Work: Indicate whether the injury occurred at work.
43. Location of Injury: Fill in the state, county, city, street address, and ZIP code of the injury location.
44. Describe How Injury Occurred: Provide a detailed description of how the injury occurred.
45. Certifier: Check the appropriate box to indicate who is certifying the death.
46. Name, Address, and ZIP Code of Person Completing Cause of Death: Provide this information.
47. Title of Certifier: Indicate the title of the certifier.
48. Certifier MO License Number: Enter the certifier's Missouri license number.
49. Certifier NPI Number: Provide the certifier's NPI number.
50. Date Certified: Enter the date the form is certified.
51. Registrar's Signature: The registrar must sign here.
52. Date Filed: Indicate the date the form is filed.
53. Decedent's Education: Fill in the highest degree or level of education completed by the decedent.
54. Decedent of Hispanic Origin: Check the appropriate box regarding the decedent's ethnicity.
55. Decedent's Race: Check one or more boxes to indicate the decedent's race.
56. Decedent's Usual Occupation: Describe the decedent's usual occupation.
57. Kind of Business/Industry: Specify the kind of business or industry.
58. Embalmed: Indicate whether the body has been embalmed.
59. Statement by Licensed Embalmer: The licensed embalmer must provide their name and license number, or that of a student working under supervision.
60. Date Certified: Enter the date the embalming was certified.