Form R-360A-09012014

CommonwealthofMassachusettsDepartmentofPublicHealth

RegistryofVitalRecordsandStatistics

InformantWorksheetforCertificateofDeath

TheinformationyouprovidebelowwillbeusedtocreatethelegalCertificateofDeath.Thedeathcertificateisapermanentdocument.

Itisveryimportantthatyouprovidecompleteandaccurateinformationforallofthequestions.Deathcertificateitemsareusedforlegalandstatisticalpurposes.Accurateandcompletedeathcertificateinformationwillhelpexpeditethesettlingofestates,assisthealthandmedicalresearcherstostudyandimprovethehealthofMassachusettsresidents,andassistgenerationsoffamilymemberswithgenealogicalinformationandtheirownmedicalhistories.ThisinformationiscollectedinaccordancewithMassachusettsGeneralLaw(c.46,§1)andaspartofanationalstandardforuniformreportingacrossallU.S.states.Pleasealsonotethatwhileyouareresponsibleforprovidinginformationforthelegalandpersonalportionsofthedeathcertificate,youshouldalsoreviewandaskquestionsofthemedicalcertifiersuchthatyouarecomfortablethatadetailedandaccuratecauseofdeathhasbeenlisted.

Pleaseprintyouranswersneatlyandaccurately.Thedeathcertificateisapermanentlegaldocumentthatisarecordofeventsandinformationatthetimeofdeathandmaynotbechangedlaterexceptunderverylimitedconditions.

DECEDENTINFORMATION

Printthedecedent’sfulllegalnameexactlyasyouwantittoappearonhisorherdeathcertificate.Enteranyaliasnames,ifany,intheAKAfields.

FirstName:

Middle Name: Check ifthedecedent doesnot havea middlename
Surname:(LastName)Generationalsuffix,ifany:(e.g.,JR,III)
Surnameat birthoradoption: (“Maiden lastname”–includeforbothmalesand females)
AKA
First nameMiddlenameSurname(Last name)

AKA
First nameMiddlenameSurname(Last name)

AKA
First nameMiddlenameSurname(Last name)

AKA
First nameMiddlenameSurname(Last name)
Sex:DateofBirth:(e.g.Mar.151935)
FemaleMale
MonthDayYear
Decedent’sSSN:Ifblank,reason:
Hasno SSNNotObtainable UnknownVerifiedwithInformant

Decedent’sAge:Enterdecedent’sageontheirlastbirthday:

AgeMeasure: YearsMonths andDays Hours andMinutes Unknown

Age:

(e.g,.33Years,10Months and4Days,15Hours and22Minutes)

PronouncementInformation:EnterifPronouncementwasperformed.IfYes,attachthePronouncementForm:

PronouncementPerformed?:YesNo

Birthplace:Enterdecedent’sbirthplace.Citiesandtownsmustbelistedbytheirlegalandpropername. Donot listaneighborhood,villageorothersub-divisionname.IfU.S.,CanadaorMexico,alsoincludetheStateorProvince.Forothercountries,listapropercity/town(orotherproperjurisdiction)aswellasthecountrynameasitexistsnow,orasitexistedatthetimeofthedecedent’sbirth.Ifnoneofthisinformationisknown,andcannotbeobtainedintimeforthedeathcertificate,pleasechecktheunknownbox.

Birthplaceunknown:

Country (Donotabbreviate,unlessU.S.)State/Province(ifCountryis U.S.,Mexicoor Canada)City/Town(Donotabbreviate)

Decedent’sResidence:Residenceistheactualaddressoftheplacewheredecedentlived.Donotuseapostofficeboxorotheraddressusedformailingpurposesonly.Thecityortownmustbelistedbyitslegalandpropername.Donot listaneighborhood,villageorothersub-divisionname.EntertheState/ProvinceiftheCountryisU.S.,CanadaorMexico.DonotabbreviateCity/Town,State/ProvinceorCountryentries.

Residence:

Streetnumberandname(e.g.,9NinthStreet)Apartmentorunit,ifany(e.g.,Apt.9)

Proper City/Townname(e.g.,Boston,notMattapan)State/Province(ifCountryis U.S.,Mexicoor Canada)ZipCode

IfNotinMassachusetts,diddecedentlivewithincitylimits?

CountryofResidence(e.g.,U.S.,Canada)

Yes NoUnknown

MaritalInformation:Enterdecedent’smaritalstatusinformation:

MaritalStatus:

MarriedMarriedbut SeparatedWidowedNeverMarriedDivorcedUnknown

LastSpouse’sInformation:Enterthedecedent’slastspouse’sinformation:

LastSpouseInformationUnknown:

FirstName:

MiddleName:

Surname:(LastName)Generationalsuffix,ifany:(e.g.,JR,III)

Surnameatbirthoradoption:(“Maidenname” –includeforbothmalesandfemales)

Mother/ParentInformation:EnterthenameoftheparentthatwillappearintheMother/Parentsectionofthedecedent’sdeathcertificate.Separatethefirst,middle,andsurnamefieldsintheboxesbelow:
NameofMother/ParentUnknown:

FirstName:

MiddleName:
Surname:(LastName) / Generationalsuffix,ifany:(e.g.,JR,III)
Surnameatbirthoradoption:(“Maidenname” –includeforbothmalesandfemales)
CountryofBirth: / State/Provinceof Birth: (ifCountryisU.S.,CanadaorMexico)
Father/ParentInformation:EnterthenameoftheparentthatwillappearintheFather/Parentsectionofthedecedent’sdeathcertificate.Separatethefirst,middle,andsurnamefieldsintheboxesbelow:
NameofFather/ParentUnknown:

FirstName:

MiddleName:
Surname:(LastName) / Generationalsuffix,ifany:(e.g.,JR,III)
Surname at birthoradoption: (“Maiden name”–includeforboth malesand females)
CountryofBirth: / State/Provinceof Birth: (ifCountryisU.S.,CanadaorMexico)
VeteranStatusInformation:Enterthedecedent’sveteranstatus.IfthedecedentisaUSveteran,completetheVeteranInformationWorksheetandattachittotheendofthisworksheet.
Isdecedent aUSVeteran?:YesNoUnknown

Decedent’sEthnicity:Informationaboutethnicitieshelpresearchersunderstandmoreaboutgeneticconditions,cultures,andlocationsofexistingandnewethniccommunitiesthatmayaffecttheavailabilityofqualitycareservicesandmedicalprograms.

Pleaseindicatedecedent’sethnicbackground(s):Youmaychoosemorethanone.

African(specify): / Korean
African-American / Laotian
American / Mexican,MexicanAmerican,Chicano
AsianIndian / Middle Eastern (specify):
Brazilian / Native American(specifytribal nation(s)):
Cambodian
Cape Verdean / Portuguese
CaribbeanIslander(specify): / PuertoRican
Chinese / Russian
Colombian / Salvadoran
Cuban / Vietnamese
Dominican / OtherAsian (specify):
European(specify): / OtherCentralAmerican(specify):
Filipino / OtherPacific Islander(specify):
Guatemalan / Other Portuguese (specify):
Haitian / Other SouthAmerican (specify):
Honduran / Otherethnicity(ies) not listed (specify):
Japanese
Unknown / Not Obtainable
Refused

Decedent’sRace:Informationaboutracehelpsresearchersunderstandmoreaboutdeathrates,healthconditionsandotherfactorsrelatingtoracethatmayaffecthealthserviceneedsinMassachusettscommunities.

Pleaseindicatedecedent’srace(s):Youmaychoosemorethanone.
AmericanIndian/ Alaska Native / Native AmericanHispanic / Latino/ Black
Asian / Hispanic / Latino/ White
Black / Hispanic / Latino/ Other(specify):
Guamanianor Chamorro / Native Hawaiian
Not Obtainable / Samoan
Refused / White
Unknown / OtherPacific Islander
Other (specify):

Decedent’sCertificateRace:Enterraceasyouwantittoappearondeathcertificate(upto42characters).

RaceonDeathCertificate:

Decedent’sEducation:InformationabouteducationhelpsresearchersunderstandmoreabouttrendsinageandeducationlevelsofMassachusettsresidents, readinglevelrequiredforhealtheducationmaterials,healthinformationneeds,andotherfactorsthatmayaffecthealth.

8thgradeorless / 9th–12thgrade
Highschool graduate or GED / Some college credit,butnodegree
Certificate / Associate’sdegree (e.g.,AA,AS)
Bachelor’sdegree (e.g.,BA,AB,BS) / Master’sdegree (e.g.,MA,MS,MBA)
Doctorate or Professionaldegree (e.g.,PhD,MD,JD) / Unknown

Refused

Decedent’sOccupationandIndustry:Informationaboutjobsresidentsholdhelpsresearchersfindoutmoreabouthowcertainoccupationsandindustriesmayaffecthealth.Certainjobconditionssuchasexposurestotoxicpaintsandchemicalsandhigh-stressindustriesmayaffecthealthandbelinkedtocertainhealthconditions.

Usualoccupation/jobduringdecedent'slifetime:

Examples: Computer programmer,Cashier,Homemaker,Student

InWhat Industry:(Youmaylistanindustryora companyname)Examples: SoftwareCompany,Supermarket,Ownhome,College

Informant’sName:Printinformant’snameexactlyasyouwantittoappearondeathcertificate.Separatethefirst,middle,andlastnamesintheboxesbelow.Theinformantshouldnotbethedecedent.Iftheprimaryinformantwasthedecedent,thefuneraldirectormustmakeanoteontheworksheet.

FirstName:

MiddleName:

Surname:(LastName)Generationalsuffix,ifany:(e.g.,JR,III)

Relationship to decedent: Husband SpouseWifeFather Mother Brother SisterSon DaughterNiece

NephewMedicalExaminer Funeral Director MedicalRecords Other

SpecifyOther:

Informant’sMailingAddress:Enterinformant’smailingaddress.DonotabbreviatetheState/Provincename.EntertheState/ProvinceiftheCountryisU.S.,CanadaorMexico.Leaveitblankifothercountry.

Streetnumber andname(e.g.,9NinthStreet)orP.O.BoxApartmentorunit,ifany(e.g.,Apt.9)

City/Townname

State/Province(ifCountryis U.S.,Mexicoor Canada)ZipCode

Country,ifnotU.S.

Worksheetcompletedby:

Please sign:DateofSignature