TEXT: Reg. Di,f. N".: ____ _ 
  l'rim~r)' Reg. Disi. No: 
  COMMONWEALTH OF MASSACHUSETIS 
  DEPARTMENT OF H EALTH 
  VITAL STATISTICS 
  State File No.: 
  Registrar'S No.: ____ 
  ~ 
  CERTIFICATE OF DEATH 
  DeCL""{!cm's Name: 
  Sex: 
  Marital Stams: 
  Surviving Spousc: 
  Race: 
  I 
  Education: 
  Place of Death: 
  F3cility N30le (address if residenCl:): 
  o Hospital 
  Decedent's Residence: 
  o Inpatient o Outpatient ODOA 
  o Other (specify) 
  Age (from hlst birti1(i3y): 
  Date of Birth: 
  Date of Death: 
  Decedent's Usual On:upation: 
  Under I year (months/days): 
  Birthplace: 
  Kind or Business/Industry: 
  Under 1 day (hours/minutes): 
  Father's Name: 
  Mailing Address: 
  Morher's Name: 
  Inform3nr's N3me: 
  Registrar's Signanm:: 
  Date Filed: 
  Signamre of Person Issuing Permit for Disposition: 
  Date Permit isslled: 
  Method of Disposition: 
  Place of Disposition (cemetery, etc.): 
  o Buri:11 
  o Cremation 
  o Removal from State 
  o Donation 
  o Other (specify) 
  Name of Embalmer: 
  License #: 
  Signature of Funeral Director or mher person: 
  License # : 
  Date of Disposition: 
  Certifier (Check only one): 
  o Certifying Physician 
  '10 Ihe beSt ofml' knowledge, de.llh t)eellm:d JI Ihe lime, plJec, ~nd JJle JIl<.! due 10 the <.'3u.",(s) Jnd manner as specified. 
  o Coroner 
  On the basis uf (:xamination and/or ill\·L~figJIi<,n. 1110 my opinlun, UcJth ll((urn;d ~t rhe time, Jan:, and plJc(:, and dt~ 10 lhe c::tusc(s) and manr~r as ~tJted. 
  Certifier's Signature and Title: 
  Licensc #: 
  I 
  D,1fe signed: 
  Time of Death: 
  Name and Addres~ of Person who Completed Cause of Death: 
  D:1[e Pronounced Dead: 
  Was else Referred to Coroner? 
  DYes 
  ONo 
  Immediate Cause (final disease or condition resulting in death): 
  , Approximate interval between onset and death: 
  , , , , , , 
  , 
  , 
  Sequemially list conditions, if all)" 
  , , 
  leading to immediate cause. Enter 
  b 
  , , 
  UNDERLYING CAUSE (disease 
  , 
  or injury that initiated events result-
  , 
  , , 
  ing in dl-:tth) LAST. 
  , 
  d 
  , , 
  Other significant conditions (contributed to death, bur not resulting in Undcrlying Cause): 
  Were Autopsy findings avail-
  Was Autop.~y pcrforml-d? 
  able prior to completion of 
  DYes 
  Cause of Death? 
  ONo 
  DYes 
  ONo 
  Manner of Death: 
  Date of Injury: 
  Time of Injury: 
  Describe how Injury occurred: 
  o Nanlral 
  o Pending Investigation 
  o Accident 
  o Could not be determined 
  o Suicide 
  Place of Injury: 
  Injury at Work? 
  Location: 
  o Homicide 
  
SOURCE: textdata/thevault/Call of Cthulhu (CoC) (BRP) [multi]/EXTRA/Resources/Props/CoC - Prop - Certificate of Death.pdf