HomeMy WebLinkAbouthandbook-death-sectionDEATH CERTIFICATE
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The Certificate of Death (VS 11)
Overview
Each death shall be registered with the local registrar in the district in which the death was
officially pronounced or where the body was found, within eight days after the death, and prior
to any disposition. This section provides information on using the Electronic Death Registration
System (EDRS) to complete the death certificate and the registration process.
REFERENCE: Health and Safety Code Section 102775
Information contained in this section includes:
Registration of Deaths ........................................................................................... 5
Importance of death registration ............................................................................................... 5
Legal uses .................................................................................................................................... 5
Statistical uses ............................................................................................................................. 5
Medical and health research ...................................................................................................... 5
Peace Officer killed in the line of duty ........................................................................................ 6
Responsibilities of the Funeral Director, Physician and Coroner ............................ 6
Responsibilities for death registration ........................................................................................ 6
Funeral director responsibility .................................................................................................... 6
Physician responsibility ............................................................................................................... 6
Physician's attestation/certification ........................................................................................... 7
Shipboard Physicians .................................................................................................................. 7
In attendance .............................................................................................................................. 7
Deaths to be reported to the Medical Examiner/Coroner ......................................................... 8
Medical Examiner/Coroner responsibility .................................................................................. 8
Medical Examiner/Coroner investigation authority ................................................................... 9
When Medical Examiner/Coroner is required to sign ................................................................ 9
Physician and Medical Examiner/Coroner both attest/sign ....................................................... 9
Additional Medical Examiner/Coroner criteria ........................................................................... 9
No Medical Examiner/Coroner involvement in military deaths ............................................... 10
Requirements for Completing the Death Certificate ............................................ 11
Persons completing the form ................................................................................................... 11
English Only ............................................................................................................................... 11
Appropriate Punctuation .......................................................................................................... 11
No Alterations ........................................................................................................................... 11
Use of “Pending” ....................................................................................................................... 11
Eight Day Calculation ................................................................................................................ 11
Issuing a Permit ......................................................................................................................... 12
Stacking Entries ......................................................................................................................... 12
Decedent's Personal Data (Fields 1-19) ................................................................ 13
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General Information (Fields 1-19)............................................................................................. 13
1, 2, & 3 Name of Decedent ...................................................................................................... 13
AKA First Name, Middle Name, Last Name and Suffix ............................................................. 14
4 Date of Birth ........................................................................................................................... 15
5 Age ........................................................................................................................................ 16
6 Sex ......................................................................................................................................... 17
7 Date of Death ........................................................................................................................ 17
8 Hour ....................................................................................................................................... 17
9 Birth State/Foreign Country .................................................................................................. 18
10 Social Security Number ....................................................................................................... 20
11 Ever in US Armed Forces? .................................................................................................... 21
12 Marital status ....................................................................................................................... 21
13 Education (Highest Level/Degree) ....................................................................................... 22
14/15 Was Decedent Spanish/Hispanic/Latino? ...................................................................... 23
16 Decedent’s Race ................................................................................................................... 24
17 Usual Occupation ................................................................................................................. 26
18 Kind of Business or Industry ................................................................................................ 27
19 Years in Occupation ............................................................................................................. 28
20 Decedent’s Residence .......................................................................................................... 28
21 City ....................................................................................................................................... 32
22 County/Province .................................................................................................................. 32
23 Zip Code ............................................................................................................................... 32
24 Years in County .................................................................................................................... 33
25 State/Foreign Country ......................................................................................................... 34
25A Homeless Checkbox ........................................................................................................... 35
26 Informant Name and Relationship ...................................................................................... 36
27 Informant Mailing Address .................................................................................................. 38
28, 29, & 30 Name of Surviving Spouse/SRDP .......................................................................... 41
31, 32, & 33 Father/Parent’s Legal Names ............................................................................... 42
34 Father/Parent’s Birth State or Foreign Country .................................................................. 42
35, 36, & 37 Mother/Parent’s Legal Birth Names .................................................................... 44
38 Mother/Parent’s Birth State or Foreign Country ................................................................. 44
39 Date of Disposition ............................................................................................................... 46
40 Place of Final Disposition ..................................................................................................... 47
41 Type of Disposition(s) .......................................................................................................... 50
42 and 43 Signature of Embalmer and Embalmer's License Number ...................................... 53
44 Name of Funeral Establishment ........................................................................................... 54
45 Funeral Establishment License Number .............................................................................. 54
46 Signature of Local Registrar ................................................................................................. 55
47 Registration Date ................................................................................................................. 55
Place of Death (Fields 101-106) ........................................................................... 56
101 Place of Death ................................................................................................................... 56
102 & 103 If Hospital, Specify One/If Other Than Hospital, Specify One ................................. 58
104 County/Jurisdiction of Death ............................................................................................. 58
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105 Facility Address or Location Where Found ........................................................................ 60
106 City .................................................................................................................................... 62
Cause of Death (Fields 107-113) .......................................................................... 64
Cause of Death Overview .......................................................................................................... 64
107A Immediate Cause ............................................................................................................ 64
107B Due to .............................................................................................................................. 64
107C Due to .............................................................................................................................. 64
107D Due to ............................................................................................................................. 65
108 Death Reported to Coroner? ............................................................................................. 66
Referral Number ....................................................................................................................... 66
Medical Examiner/Coroner Referral Reasons .......................................................................... 67
109 Biopsy Performed? ............................................................................................................ 69
110 Autopsy Performed? ......................................................................................................... 69
111 Used in Determining Cause? ............................................................................................. 69
112 Other Significant Conditions Contributing to Death but Not Resulting in the Underlying
Cause Given in 107 .................................................................................................................... 70
113 Was Operation Performed for Any Condition in Fields 107 or 112? (If yes, list type of
operation and date) .................................................................................................................. 70
113A If Female, Pregnant in Last Year? ................................................................................... 71
Physician’s Certification (Fields 114-118) ............................................................. 73
114A and 114B Dates of Attendance ........................................................................................ 73
115 & 116 Signature and Title of Certifier & License Number ................................................. 73
117 Date Certifier Signed .......................................................................................................... 75
118 Attending Physician’s Name and Mailing Address ............................................................ 76
Coroner’s Use Only (Fields 119-128) .................................................................... 79
119 Manner of Death (Coroner’s Use Only) ............................................................................. 79
120 Injured at Work? ................................................................................................................ 80
121 Injury Date .......................................................................................................................... 80
122 Hour................................................................................................................................... 81
123 Place of Injury.................................................................................................................... 82
124 Describe How Injury Occurred ........................................................................................... 82
125 Location of Injury ............................................................................................................... 83
126 Signature of Coroner/Deputy Coroner .............................................................................. 86
127 Date .................................................................................................................................... 86
128 Typed Name, Title of Coroner/Deputy Coroner ................................................................ 86
Court Order Delayed Registration of Death (VS 109) ........................................... 87
Description ................................................................................................................................ 87
Filing the VS 109 ........................................................................................................................ 87
Fees ........................................................................................................................................... 87
Certified copy of court order .................................................................................................... 87
Certified copy of certificate ...................................................................................................... 88
Amending court ordered delayed certificates .......................................................................... 88
Mass Fatalities ..................................................................................................... 89
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Overview ................................................................................................................................... 89
Definition .................................................................................................................................. 89
Filing of petition with the clerk of the superior court .............................................................. 89
Initial contact ............................................................................................................................ 89
Obtaining forms ........................................................................................................................ 90
Standard certificates ................................................................................................................. 90
Fee ............................................................................................................................................. 90
Amending court order delayed certificates .............................................................................. 90
Remains later located and identified ........................................................................................ 90
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Registration of Deaths
Importance of death registration
A death certificate is a permanent record of the fact of death for an individual. It provides
important personal information about the decedent, circumstances, and cause of death.
Information from death records serves several important legal and statistical uses described
below.
Legal uses
Upon registration by the local and state registrar, the death certificate becomes the state's legal
record of that event and is prima facie (e.g. accepted as correct until proven otherwise)
evidence in all courts.
Additionally, the death certificate is used to:
• Apply for insurance benefits
• Settle pension claims
• Verify transfer of title and personal property
REFERENCE: Health and Safety Code Section 103550
Statistical uses
Information from a death certificate provides a critical source of data and information about
the health of a population. These data help to define problems and measure the results of
many aspects of public health work.
Medical and health research
In general, mortality data are part of a necessary foundation used to evaluate population well-
being and the effectiveness of health care and public health interventions and policies. These
data can be used across several different areas of interest and study, including:
• Mortality counts and rates.
• Life expectancy.
• Years of life lost (YLL).
• Disability Adjusted Life Years (DALY).
• Quality Adjusted Life Years (QALY).
• Disease surveillance.
• Demographic projections.
• Geographic distribution of deaths from certain diseases.
• Risk of death from various causes at different ages.
• Health disparities and inequities.
• Impacts of the social determinants of health.
• Medical implications of the combinations of morbid conditions (e.g. illnesses or
diseases) causing death.
• Frequency of autopsies, and
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• Proportion of deaths occurring in health care facilities and congregate settings, such as
hospitals or nursing homes.
Peace Officer killed in the line of duty
When a peace officer is killed in the line of duty, the law requires special processing of the
death certificate with exceptional speed. Extra measures are taken to communicate with the
informant, Medical Examiner/Coroner and local registrar to complete the certificate timely.
REFERENCE: Health and Safety Code Section 103265, ACL 03-25
Responsibilities of the Funeral Director, Physician and Coroner
Responsibilities for death registration
The responsibilities of the funeral director, physician, and the county Medical
Examiner/Coroner in the registration of deaths are defined in this section.
Funeral director responsibility
The funeral director, or person acting in lieu of, is responsible for the duties described below:
• Obtaining the decedent’s personal data from the informant (the person available to
supply this information (see H&SC Sec. 7100 for more information)
• Ensuring all fields of the certificate are complete
• Notifying the coroner of any death that is required by law to be reported unless the
physician or the police have already done so (refer to the section regarding deaths
required to be reported to the coroner)
• Securing the physician’s or coroner’s certification signature
• Reviewing the certificate for completeness and accuracy
• Filing the certificate with the local registrar within eight (8) calendar days and obtaining
a permit for final disposition
• Cooperating with state or local registrars concerning queries on certificate entries
REFERENCE: Health and Safety Code Sections 102125, 102135, 102780, 102790, 102850,
103785 and Government Code Section 27491
Physician responsibility
The physician in attendance shall, within 15 hours after the death, provide and attest to the
following information contained on the Certificate of Death (VS 11):
• The date, time, and place of death
• The direct causes of death
• The conditions, if any, that gave rise to these causes
• Other medical and health section data required on the certificate
• If appropriate, the existence of cancer
During the remote attestation process, the physician reviews the information for accuracy,
electronically attests to these facts and notifies the attending funeral director that the
attestation is complete.
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REFERENCE: Health and Safety Code Section 102795, 102800 and 102825
Physician's attestation/certification
The following rules apply to the physician's signature on a death certificate:
• Licensed California physicians may attest or sign the certificate.
Deaths may not be certified or attested by medical residents or interns who have not
been issued a medical license.
• Federally employed physicians, state civil service physicians, shipboard physicians on the
high seas, and county hospital physicians who are licensed out-of-state are considered
provisionally licensed to legally sign a California death certificate.
• If an out-of-state physician has attended the decedent in the 20 days before death, and
the death is not otherwise a coroner's case, the physician has the authority to sign the
death certificate. The decedent need not have died in the federal, state or county
facility, or on federal, state or county property.
REFERENCE: Business and Professions Code Section 715, 2060, and Health and Safety Code
Section 102850, Government Code Section 27491
Shipboard Physicians
Shipboard physicians may sign a California death certificate, provided all of the following
conditions are met:
• The decedent dies after disembarking, but within 20 days of attendance by the
shipboard physician
• The physician is licensed in another state or country with laws and standards for
shipboard physicians similar to those of the United States, such determination being at
the discretion of the county medical examiner/coroner of the jurisdiction in which the
decedent was first removed from aboard ship (first port of call)
• The physician was the last physician to attend on the decedent within the 20 days
before death
• The case is not otherwise a coroner's/medical examiner's case. If the Medical
Examiner/Coroner determines the shipboard physician has adequate knowledge to
determine the cause of death, the Medical Examiner/Coroner may authorize the
shipboard physician to sign the California death certificate
REFERENCE: Business and Professions Code Section 2060, Health and Safety Code Section
102850 and Government Code Section 27491
In attendance
“In attendance” means the existence of the relationship whereby a health care provider
renders services which are authorized by the health care provider's licensure or certification.
REFERENCE: California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter 1, Article
1, number 17
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Deaths to be reported to the Medical Examiner/Coroner
Deaths due to the following must be referred to the Medical Examiner/Coroner office:
• Violent, sudden, or unusual
• Unattended
• The deceased had not been attended by a physician in 20 days prior to death
• Known or suspected homicide, suicide, or accidental poisoning
• Known or suspected in whole or in part to be from or related to an accident or injury
(either old or recent)
• Deaths due to drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation,
acute alcoholism, drug addiction, strangulation, aspiration, or where the suspected
cause of death is sudden infant death syndrome (not including aspiration pneumonia)
• Death in whole or in part occasioned by criminal means
• Deaths associated with a known or alleged rape or crime against nature
• Deaths in prison or while under sentence
• Known/suspected due to contagious disease and constituting public hazard
• Deaths from occupational diseases or occupational hazards
• Deaths of patients in state mental hospitals serving the developmentally disabled and
operated by the state department of mental health
• Deaths under such circumstances as to afford a reasonable ground to suspect the death
was caused by the criminal act of another
NOTE: When a death involves any of the above, it is the responsibility of the funeral director,
physician, surgeon, physician assistant, or other person, including local registrar to notify the
medical examiner/coroner and confirm the medical examiner/coroner’s clearance for the
physician to complete the medical certification.
REFERENCE: Government Code Section 27491, Health and Safety Code Section 102850
Medical Examiner/Coroner responsibility
The Medical Examiner/Coroner shall, within three days after examining the body, state and
certify the following information on the Certificate of Death (VS 11):
• The date, time, and place of death
• The direct causes of the death
• The conditions, if any, that gave rise to these causes
• Other medical and health section data required on the certificate
• If appropriate, the existence of cancer
During the attestation process, the Medical Examiner/Coroner reviews the information for
accuracy, electronically attests to these facts and notifies the attending funeral director the
attestation is complete.
REFERENCE: Health and Safety Code Section 102800, 102850, 102860 and Government Code
27491
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Medical Examiner/Coroner investigation authority
The Medical Examiner/Coroner investigates cases under his or her jurisdiction in which death
occurred under any of the following circumstances:
• Without medical attendance
• During the continued absence of the attending physician and surgeon
• When the attending physician is unable to state the cause of death
• Where suicide is suspected
• Following an injury or an accident
• Under circumstances as to afford a reasonable ground to suspect the death was caused
by the criminal act of another
REFERENCE: Health and Safety Code Section 102850, Government Code Section 27491
When Medical Examiner/Coroner is required to sign
The medical examiner/coroner shall attest/sign the death certificate under the following
criteria:
• If the attending physician is unable to state the underlying cause of death
• If death is due to an external cause
• If no physician was in attendance
• If the attending or assistant physician is not available to sign
• If field 26 (informant) on the death certificate states "under investigation"
The medical examiner/coroner may authorize the physician to attest to or sign the certificate.
REFERENCE: Health and Safety Code Section 102850, 102860 and Government Code Section
27491
Physician and Medical Examiner/Coroner both attest/sign
There may be cases where the physician certifier has completed the medical and health section
data and Fields 114 through 118, and the Medical Examiner/Coroner subsequently assumes
jurisdiction over the death. Under these circumstances, the coroner may sign the certificate and
add information previously left blank without the need to prepare a new certificate.
Additional Medical Examiner/Coroner criteria
Individual county Medical Examiner/Coroners may require that deaths occurring under other
circumstances also be reported to the coroner's/medical examiner's office. Contact the coroner
of the county with jurisdiction over the death for additional information.
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No Medical Examiner/Coroner involvement in military deaths
Attorney General's opinion (1 Ops. Cal. Atty. Gen. 176, page 182, 1943) states specifically when
the coroner should and should not become involved:
“…it is the opinion of this office that the county coroner may not act with reference to
unnatural deaths occurring within military reservations under the exclusive jurisdiction of the
federal government, deaths occurring in the line of duty of military personnel or where his
activity will impede or hamper military operations. In case of deaths occurring under other
circumstances, the coroner should exercise the authority of this office."
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Requirements for Completing the Death Certificate
Persons completing the form
All physicians, informants, and other persons having knowledge of the facts shall supply upon
the prescribed forms, any information they possess regarding any death. The certificate form
shall be completed in accordance with the requirements set forth in the Health and Safety
Code.
REFERENCE: Health and Safety Code Sections 102135, 102790 and 102875
English Only
The form is to be completed using the 26 alphabetical characters of the English language.
REFERENCE: Constitution of California, Article 3, Section 6 and Government Code Section 8
Appropriate Punctuation
Appropriate punctuation should be used for all entries. Examples of appropriate punctuation
for purposes of vital records are as follows:
• Hyphens such as "Smith-Jones"
• Apostrophe as in "O’Hare"
• Period as used with "Jr."
No Alterations
No erasures, whiteout, or alterations of any kind are allowed on the printed certificate.
NOTE: If errors are discovered prior to submission for registration, return to EDRS and correct
the errors. If the certificate has been submitted for registration but has not yet been
registered, contact your local registrar. If it has been registered, an amendment will be
necessary to correct the error.
REFERENCE: Health and Safety Code Section 102140
Use of “Pending”
An entry of "Pending" in one or more fields is only acceptable for coroner cases, at the direction
of the coroner.
Eight Day Calculation
Each death must be registered within eight (8) days following the date of death and prior to
disposition. The eight-day filing mandate is calculated by excluding the date of death and
counting each day thereafter, unless the eighth day falls on a Sunday or county holiday, at
which time the ninth day would be the final day the death must be registered. Saturday is not
treated in statute as a holiday.
REFERENCE: Government Code Sections 6700, 6701, and 6800
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Issuing a Permit
A permit for disposition shall be issued only when an acceptable death certificate has been
registered.
REFERENCE: Health and Safety Code Section 103050
Stacking Entries
EDRS controls which fields accept "stacking entries" where more than one line of text is
allowed. This is done to ensure the information provided is legible, unambiguous, reproducible,
and contained within the appropriate field area.
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Decedent's Personal Data (Fields 1-19)
General Information (Fields 1-19)
The Decedent Personal Data section contains Fields 1 through 19. The collection of this
information is authorized in statute.
REFERENCE: Health and Safety Code Section 102875
Following are the specific instructions for completing these fields.
1, 2, & 3 Name of Decedent
Do not leave any of these items blank. Enter a dash (-) if necessary.
Enter the decedent’s legal first, middle and last names in the appropriate fields.
• 1 First Name
• 2 Middle Name
• 3 Last Name
Only the 26 alphabetical characters of the English language may be used. No pictographs,
ideograms, or diacritical marks (è, ñ, ē, ç) are allowed. A dash (-), period (.), or apostrophe (') is
acceptable punctuation. Only one line is allowed in each field. Multiple names in a field may not
be stacked.
Legal names for purposes of vital event records are those acquired through birth, adoption,
naturalization, court-ordered name change, or marriage. The names must fit the available space
on the official Certificate of Death Form. In the case of long or hyphenated names, it may be
necessary to shorten the name to fit the available space. In this case, when the certificate is
completed, create an Affidavit to Amend a Record (VS 24e) to show the full name(s). The
certificate will become a multiple-page document with the full name listed on an additional
page of the document.
If the decedent has more than one name, the name to be entered in Fields 1 through 3 is the
name that was used to verify the Social Security Number. If there was no Social Security
Number verification, utilize the name used for official purposes in the United States (e.g., a
driver’s license, tax purposes, voter registration, etc.). If there is another name, it should be
placed in the AKA (Also Known As) field.
After record creation and before registration, the name of decedent can be updated using the
Edit Decedent Information menu option.
Suffix
Select the appropriate suffix for the decedent from the dropdown. If the decedent does not
have a suffix, this field may be left as a double dash (--).
Jane/John Doe number
If the decedent has not been identified and is considered a John or Jane Doe, a number (e.g.,
John/Jane Doe number) may be used if it is the medical examiner/coroner’s policy. This option
is only available if the coroner has accepted the case (coroner status=ACC).
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What to do…
If the decedent … Then …
has only one name enter a dash (-) in Fields 1 and 2 and the name in Field 3.
has no first or middle name enter a dash (-) in the appropriate field.
has a hyphenated name enter the complete name in the appropriate field, space
permitting. If additional space is needed, then submit an
Affidavit to Amend a Record (VS 24e) after the certificate is
registered.
has long or multiple names
and additional space is
necessary
enter as many characters as permitted by available space. If
additional space is needed, then submit an Affidavit to
Amend a Record (VS 24e) after the certificate is registered.
has not been identified the medical examiner/coroner will enter John Doe or Jane
Doe in Fields 1 and 3, and a dash (-) in the middle name
Field 2. A number, (e.g., John Doe No. 2) may be used if it is
the medical examiner/coroner’s policy. Enter the number in
the John/Jane Doe number field. Do not enter Unknown or
Unidentified Male, or Unidentified Female.
is known by an AKA (also
known as)
enter only the legal name in Fields 1, 2, and 3. See the AKA
section for information regarding AKA’s.
is a newborn the name as it appears on the certificate of birth should be
entered on the death certificate. However, if the parents
request a different name be placed on the death certificate,
list the birth certificate name as an AKA.
is an unnamed newborn enter a dash (-) for Fields 1 and 2 and the last name of the
parent in Field 3.
AKA First Name, Middle Name, Last Name and Suffix
Enter the AKA (Also Known As) First Name, Middle Name, Last Name and Suffix as provided by
the informant in the appropriate fields. Only one AKA is permitted on the death certificate.
Names must be alphabetic. A dash (-), period (.), or apostrophe (') is acceptable punctuation.
Additional AKAs must be added via an Affidavit to Amend the Record (VS 24). Refer to the
Death Amendment section of this handbook for further information regarding multiple AKAs.
If the decedent does not have an AKA, these fields may remain blank.
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What to do…
If the decedent’s … Then …
name is John Anthony Harris
and he has an AKA first name
of Red
enter Red in the AKA First Name field, Anthony in the AKA
Middle Name field and Harris in the AKA Last Name field.
name is Elizabeth Mary Jones
and she has an AKA of Betty
Jones-Harris
enter Betty in the AKA First Name field, Mary in the AKA
Middle Name field and Jones-Harris in the AKA Last Name
field.
has an AKA of Betty Jones-
Harris
enter Betty in the AKA First Name, leave the AKA Middle
Name field blank, and Jones-Harris in the AKA Last Name
field.
4 Date of Birth
Do not leave this field blank.
Enter the decedent’s date of birth using the calendar tool or enter the date using the
MM/DD/YYYY format.
If the day and/or month are unknown, use double dashes as placeholders for the absent
information.
EDRS uses the Date of Birth (Field 4) and the Date of Death (Field 7) to automatically calculate
age whenever possible when information is saved.
However...
• if the date of death is "FOUND", the estimated age must be manually entered into Field
5.
• if the date of birth is partial or unknown, the estimated age must be manually entered
into Field 5.
• if calculated age is one day or less, the age in days, hours, and/or minutes must be
manually entered into Field 5.
What to do...
If … Then enter …
the day of birth is unknown the estimated month and year with dashes for the unknown
day separated by forward slashes (e.g., 07/--/1998).
the month and day of birth are
unknown
the year with dashes for the unknown month and day
separated by forward slashes (e.g., --/--/2010).
no information is available UNK.
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5 Age
EDRS uses the Date of Birth (Field 4) and the Date of Death (Field 7) to automatically calculate
age whenever possible when information is saved.
However...
• if the date of death is "FOUND," the estimated age must be manually entered into Field
5.
• if the date of birth is partial or unknown, the estimated age must be manually entered
into Field 5.
• if calculated age is one day or less, the estimated age in days, hours, and/or minutes
must be manually entered into Field 5.
If EDRS does not automatically calculate age, manually enter the age at the time of death.
Select the appropriate age type from the dropdown in Field 5. The available options are:
• Years
• Under One Year
• Under 24 Hours
After an age type has been designated, a subsequent field will populate, requesting further
details regarding the age. Enter the age at the time of death.
What to do...
If … Then select …
years Years from the Age dropdown. Enter the number of years.
under one year Under One Year from the Age dropdown. Then select the
appropriate number from the months and/or days
dropdowns.
under one day Under 24 Hours from the Age dropdown. Then select the
appropriate number from the hours and/or minutes
dropdowns.
unknown years Years from the Age dropdown. Then enter UNK.
unknown months Under One Year from the Age dropdown. Then select UNK
from the Months dropdown.
unknown days Under One Year from the Age dropdown. Then select UNK
from the Days dropdown.
unknown hours Under 24 Hours from the Age dropdown. Then select UNK
from the Hours dropdown.
unknown minutes Under 24 Hours from the Age dropdown. Then select UNK
from the Minutes dropdown.
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6 Sex
Select the appropriate sex from the dropdown. The available options are:
• Male (M will print)
• Female (F will print)
• Unknown/Undetermined (U will print)
• Nonbinary (X will print)
After record creation and before registration, decedent sex may be updated using the Edit
Decedent Information menu option.
REFERENCE: Health and Safety Code Section 102875
7 Date of Death
Enter the date of death certified by the physician or coroner using the calendar tool or enter
using the MM/DD/YYYY format.
Do not leave blank.
If the death is accepted as a coroner's case (coroner status=ACC), and the date of death is not
known, enter the date the body was found and select the abbreviation FND from the drop-
down list.
After record creation and before registration, the date of death may be updated using the Edit
Decedent Information menu option.
NOTE: Please be certain the YEAR of death is correct BEFORE registration. YEAR of death
cannot be amended. If the year is not correct, the original death certificate will need to be
administratively sealed and a replacement death certificate with the correct date will be
required.
Court Order Delayed Registration of Death is required for deaths that occurred more than one
year ago. For more information, please visit: Court Ordered Delayed Registration of Death.
8 Hour
Enter the 24-hour military clock time (i.e., HHMM) that the physician or medical
examiner/coroner certifies as the time of event. For example, 4:16 p.m. is entered as 1616. If
the decedent was found (FND entered in Field 7) and the hour of death is not identified, enter
UNK. If time of event is unknown, enter UNK. Do not enter seconds, colons, dashes, or other
punctuation.
After record creation, the time of death may be updated using the Edit Decedent Information
menu option.
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Please refer to the time conversion table below.
TIME CONVERSION TO 24-HOUR CLOCK
Regular Clock 24-Hour Clock Regular Clock 24-Hour Clock
12:00 a.m. 0000 12:00 noon 1200
1:00 a.m. 0100 1:00 p.m. 1300
2:00 a.m. 0200 2:00 p.m. 1400
3:00 a.m. 0300 3:00 p.m. 1500
4:00 a.m. 0400 4:00 p.m. 1600
5:00 a.m. 0500 5:00 p.m. 1700
6:00 a.m. 0600 6:00 p.m. 1800
7:00 a.m. 0700 7:00 p.m. 1900
8:00 a.m. 0800 8:00 p.m. 2000
9:00 a.m. 0900 9:00 p.m. 2100
10:00a.m. 1000 10:00 p.m. 2200
11:00a.m. 1100 11:00 p.m. 2300
11:59 p.m. 2359
What to do...
If … Then …
the actual time is not known but can be
estimated
have certifier designate the best estimate and
select EST from the dropdown.
the time when the body was found is
known, but actual time of death is not
known
have certifier designate the estimated time the
body was found and select FND from the
dropdown.
if the hour is unknown or the time cannot
be estimated enter UNK.
there is an independent confirmation by
a second physician to confirm (cessation
of all functions of the entire brain)
the time of death to be recorded is the time of
the confirming (second physician’s) examination.
9 Birth State/Foreign Country
Select the decedent's birth place address type from the dropdown. The available options are:
• US State
• US Territory
• Canadian Province
• Mexican State
• Other Country
• Other Country UNK
• Unknown
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rev July 2021 --- California Death Registration 19
After an address type has been designated, a subsequent field will populate, requesting further
details regarding the birth state/foreign country.
What to do...
If … Then select …
US State
US State from the dropdown. Then select the appropriate state from
the dropdown. The US state abbreviation will print on the death
certificate.
US Territory
US Territory from the dropdown. Then select the appropriate
territory from the dropdown. The US territory abbreviation will print
on the death certificate.
Canadian Province
Canadian Province from the dropdown. Then select the appropriate
province from the dropdown. The Canadian province abbreviation
and CN will print on the death certificate.
Mexican State
Mexican State from the dropdown. Then select the appropriate state
from the dropdown. The Mexican state abbreviation and MX will print
on the death certificate.
Other Country
Other Country from the dropdown. Then use the reference browser
(click on the magnifying glass icon) to select the foreign country. EDRS
will populate the foreign country or foreign country abbreviation.
unknown US State US State from the dropdown. Then select UNK from the dropdown.
UNK will print on the death certificate.
unknown US
Territory
US Territory from the dropdown. Then select Unknown from the
dropdown. UNK will print on the death certificate.
unknown Canadian
Province
Canadian Province from the dropdown. Then select Unknown from
the dropdown. UNK, CN will print on the death certificate.
Alternatively, you may leave the Canadian Province dropdown
unselected (double dash) and CN will print.
unknown Mexican
State
Mexican State from the dropdown. Then select Unknown from the
dropdown. UNK, MX will print on the death certificate. Alternatively,
you may leave the Mexican state dropdown unselected (double dash)
and MX will print on the death certificate.
unknown Other
Foreign Country
Other Country UNK from the dropdown. No further action is needed.
FRN-UNK will print on the death certificate.
Unknown Unknown from the dropdown. No further action is needed. UNK will
print on the death certificate.
born on the high
seas
Other Country UNK. No further action is needed. FRN-UNK will print
on the death certificate.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 20
10 Social Security Number
Enter the decedent’s United States nine-digit Social Security Number (SSN), excluding
dashes. Ensure the decedent's name, date of birth and sex are accurate.
Select Request SSN Verification (SSNV) from the Certificate menu dropdown. Check the box to
confirm you have the authority to verify the SSN for this record and then select "Continue." The
First Name, Last Name, Date of Birth, Sex, and SSN will lock (cannot be edited) while verification
is Pending.
When a response is received from the Social Security Administration (SSA), the status will
update and tell you if the verification passed or failed. To view the status, go to the Status tab.
If the verification failed, examine your entries and/or contact the informant to attempt to
obtain the correct information. Correct any entries on the death certificate, and then re-
request SSNV. A maximum of five (5) attempts for SSNV is allowed.
It is not necessary to wait for a “passed,” “failed,” or “pending” response from SSA to continue
with completing and registering the certificate. Also, a certificate with a "pending" or "failed"
SSN number verification may still be submitted and registered. If a SSN is entered, the only
requirement is that SSNV has been requested at least once.
If the SSN is unknown (UNK) or there is no SSN (NONE), you are not required to Request SSNV.
If you attempt Request SSNV, SSNV validations will display a SSN red error message. However,
within EDRS validations, both UNK and NONE are acceptable entries; no red EDRS error
message will occur or prevent you from continuing the registration process.
SPECIAL CAUTION:
Once SSNV has PASSED, you cannot edit SSN. You may edit Name, DOB, Sex and re-request
SSNV, but you cannot change the SSN after getting a PASSED response. If the SSN must be
changed, then you would have to abandon the record. Also, if the certificate has been
registered with a validated SSN, any subsequent change to the SSN requires an amendment and
supporting documentation.
CA-EDRS runs validations for the entries in this field on behalf of the SSA. If an error message
occurs, refer to the EDRS 4.0 User Guide.
What to do...
If … Then enter …
the decedent did not have an SSN issued by the United States NONE
the SSN is unknown UNK
Unacceptable entries for SSN
• WITHHELD
• International SSNs.
• Identification numbers such as health insurance claim numbers and Medicare numbers.
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11 Ever in US Armed Forces?
Select the appropriate information for the decedent from the dropdown. The available options
are:
• Yes
• No
• Unknown
What to do...
If … Then select…
in the United States armed forces YES
not in the United States armed forces NO
in the armed forces, but not the United States armed forces NO
information is not known UNK
12 Marital status
Select the decedent’s marital status at the time of death from the dropdown. The available
options are:
• Never married
• Married
• Widowed
• Divorced
• Married/WID (in the case of a simultaneous death of the spouses)
• SRDP (in the case of a State-Registered Domestic Partner)
• SRDP SURV (in the case of a surviving SRDP)
• SRDP/SURV (in the case of a simultaneous death of the partners)
• Unknown (if absolutely no information is available)
The California Domestic Partner Rights and Responsibilities Act applies to partners who are
members of the same sex, and to partners who are of opposite sexes when one or both of the
partners are over 62 years of age. Other criteria for domestic partners can be located in Family
Code Section 297.
Spouse name Fields 28, 29 and 30 depends on the marital status selected. If marital status is
amended, spouse fields (Fields 28, 29, 30) may also need to be amended.
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What to do...
If Field 12 … Then Fields 28, 29, 30 …
Never Married a dash (-) is auto-populated and spouse fields are not editable.
Married enter the spouse's name in Fields 28, 29 and 30. If spouse's name is not
available, enter dash(es) (-) as appropriate.
Widowed a dash (-) is auto-populated and spouse fields are not editable.
Divorced a dash (-) is auto-populated and spouse fields are not editable.
Married/Wid enter the spouse's name in Fields 28, 29 and 30. If spouse's name is not
available, enter dash(es) (-) as appropriate.
SRDP enter the SRDP's name in Fields 28, 29 and 30.
SRDP SURV enter a dash (-) in Fields 28, 29 and 30.
SRDP/SURV enter the partner's name in Fields 28, 29 and 30. If partner's name is not
available, enter dash (es) (-) as appropriate.
UNKNOWN enter a dash (-) in Fields 28, 29 and 30.
13 Education (Highest Level/Degree)
Select the option that best describes the decedent’s highest degree or level of school
completed from the dropdown. Refer to the table below for the available options:
What to do...
If the decedent … Then …
did not complete one full year of formal
education select 0 (zero).
completed grades, 1, 2, 3…11 select the highest grade completed 1st
Grade through 11th Grade.
completed 12th grade, but did not receive a
diploma select 12th Grade with no diploma.
completed high school select High School diploma.
completed the GED (General Equivalency
Diploma) select GED.
attended college but did not receive a degree select Some College but no degree.
received an Associate degree (e.g., AA, AS) select Associate's degree.
received a Bachelor’s degree (e.g., BA, AB, BS) select Bachelor's degree.
received a Master’s degree (e.g., MA, MS, MEng,
MEd, MSW, MBA) select Master's degree.
received a Doctorate (e.g., PhD, EdD) select Doctorate degree.
received a Professional degree (e.g., MD, DDS,
DVM, LLB, JD) select Professional degree.
no information is available select Unknown.
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What to do continued...
If the decedent … Then …
attended a specialty school such as a beauty,
barber, business or technical school
do not include in the number of school
years completed.
was educated outside the USA identify and enter the number of years
school was attended in comparison to
USA education.
14/15 Was Decedent Spanish/Hispanic/Latino?
Utilize the Race Ethnicity Worksheet located in the Help menu dropdown to assist in gathering
the decedent’s Hispanic, Latino, or Spanish origin information.
Select the decedent's appropriate Hispanic, Latino, or Spanish origin information from the
dropdown in Field 14/15. The available options are:
• Yes
• No
• Unknown
If YES, next select the appropriate box(es). The available options are:
• Cuban
• Mexican
• Puerto Rican
• Other
If Other was selected, please specify. Use the reference browser (click on the magnifying glass
icon) to select the decedent's origin or ancestry (e.g., Guatemala, Nicaragua, Argentina). If the
origin or ancestry is not found using the reference browser, type the origin or ancestry in the
space provided. Hispanic origin must be alphabetic. A dash (-), period (.), apostrophe ('), or slash
(/) is acceptable punctuation. Abbreviations are acceptable.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 24
What to do...
If … Then …
not of Hispanic/Latino/Spanish origin or descent select No from the dropdown.
of Hispanic/Latino/Spanish origin or descent select Yes from the dropdown – and
specify the decedent’s origin or descent
by checking the applicable checkbox(es)
Cuban, Mexican, Puerto Rican, or Other.
of more than one Hispanic/Latino/Spanish origin
or descent
select Yes from the dropdown – and
specify the decedent’s origin or descent
by checking the applicable checkbox(es)
Cuban, Mexican, Puerto Rican, or
Other. Check to see that the entries will
fit in the space provided.
of Hispanic/Latino/Spanish origin or descent, but
specific origin or descent unknown
select Yes from the dropdown, check the
Other checkbox and enter UNKNOWN.
No information is available select Unknown from the dropdown.
16 Decedent’s Race
Utilize the Race Ethnicity Worksheet located in the Help menu dropdown to assist in reporting
the decedent’s race information.
Race entries are intended to be informant-designated. The informant may select up to three
races and choose the desired race(s) to be printed on the certificate. The informant may enter
Unknown if the information is not known.
Select race from the dropdown. The available options are:
• White
• Caucasian
• Black
• African American
• Mexican
• Mexican American
• Other Hispanic
• Alaskan Native
• Eskimo
• Aleut
• Native American
• American Indian
• Chinese
• Japanese
• Filipino
• Korean
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• Vietnamese
• Asian Indian
• Cambodian
• Thai
• Laotian
• Hmong
• Other Asian, specify
• Native Hawaiian
• Guamanian
• Samoan
• Other Pacific Islander, specify
• Unknown
• Other, specify
The race selected will be entered by default in the adjacent field. To further specify race or
national origin to be listed on the death certificate, utilize the reference browser (click on the
magnifying glass icon) to select the more specific race to print on the death certificate. The
more specific text must be consistent with the race selected from the dropdown. Ensure
accurate spelling of the entry, if the entry is misspelled, the family may request an amendment.
The race information may be truncated as necessary to fit in the space provided. Race must be
alphabetic. A dash (-), period (.), or apostrophe (') is acceptable punctuation. Facetious,
derogatory and/or extraneous (e.g., human being) entries are not acceptable.
What to do...
If … Then …
none of the categories apply select Other from the dropdown and enter the race
provided by the informant in the text field.
no information is available select Unknown from the dropdown and UNKNOWN
will auto-populate the text field.
you make a mistake and enter the
wrong race
select the correct race from the dropdown, this will
change the entry in the text field.
you make a mistake and enter a
second or third race when none
should have been selected
select the double dash (--) from the dropdown. This
will clear the race on the dropdown and clear the
entry in the text field.
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17 Usual Occupation
These recommendations are intended as guidelines only and should be used as such.
Certificates should not be rejected based on this entry alone.
Enter the type of work the decedent performed for the longest period of time. Provide the
information as stated by the informant, as specifically as possible. This field is alphanumeric. A
dash (-), period (.), apostrophe ('), ampersand (&), or parentheses is acceptable punctuation.
Auto-populate Field 17 one of two ways below:
• begin typing the first few characters of the desired occupation and a list will appear.
Select the most accurate occupation from the list; OR
• use the magnifying glass icon to access the Occupation Browser. Search for the
occupation by title by typing the first few characters. Then select the most accurate
occupation from the list.
What to do...
If the decedent … Then specify type …
was a doctor physician, dentist, veterinarian, chiropractor, etc.
worked in data processing computer programmer, key data operator, etc.
was a nurse registered nurse, nurse-midwife, nurse’s aide, nurse
practitioner, etc.
was a homemaker
homemaker. However, if the decedent normally
worked outside of their home prior to their death,
then enter that information.
was a farm worker farmer, farm hand, farm supervisor, fruit picker,
migratory farm hand, etc.
was a business owner enter owner.
was a student enter student.
was an infant (less than 12 months) enter infant.
was a child (12 months or greater) enter child.
Acceptable Entries:
• Unknown or UNK if no information is available
• Withheld
• Never Worked
• Abbreviations
Unacceptable Entries:
• Derogatory or nonsensical entries
• Retired
• Unemployed
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rev July 2021 --- California Death Registration 27
18 Kind of Business or Industry
These recommendations are intended as guidelines only and should be used as such.
Certificates should not be rejected based on this entry alone.
Enter the type of business or industry the decedent worked for the longest period of time
corresponding to the entry in Field 17. Provide the information as stated by the informant, as
specifically as possible. This field is alphanumeric. A dash (-), period (.), apostrophe ('),
ampersand (&), or parentheses is acceptable punctuation.
Auto-populate Field 18 one of two ways below:
• begin typing the first few characters of the desired business or industry and a list will
appear. Select the most accurate business or industry from the list; OR
• use the magnifying glass icon to access the business or industry Browser. Search for the
business or industry by title by typing the first few characters. Then select the most
accurate business or industry from the list.
What to do...
If business or industry is … Then specify …
mining copper mine, etc.
retail bookstore, card store, etc.
manufacturer fountain pen manufacturing, etc.
construction road construction, housing construction, etc.
oil and gas industry
oil field drilling, petroleum refinery, retail gasoline
station, wholesale oil distributor, natural gas
pipeline, etc.
for a child or infant none or a dash (-).
for a student public education, private education, home school,
etc.
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19 Years in Occupation
Enter the number of years (cumulative) the decedent worked in the occupation listed in Field
17. Round the entry to the nearest full year. Years in Occupation must be numeric, UNK if
unknown, or a dash (-) if no information is available.
What to do...
If … Then enter …
no information is available a dash (-).
the decedent is a child that has not
completed first grade
a dash (-).
the decedent is a student the highest grade completed.
the decedent worked less than six
months
0.
the decedent never worked a dash (-).
20 Decedent’s Residence
Enter the decedent’s usual and customary street or rural address in Field 20.
There are three subfields within Field 20:
• Street Number (optional)
• Street Name (required)
• Apt/Suite/Unit (optional)
Street Number (optional)
This subfield may be left blank. Enter the street number if the decedent's address included a
street number. Street number must be alphanumeric. A dash (-), period (.), slash (/), or
apostrophe (') are acceptable punctuation. Do not list homeless terms here (Unsheltered,
Sheltered, In Institution).
• 123
• 123B
Street Name (required)
Enter the street name of the decedent’s street address (see further instructions below if
decedent was homeless). If the decedent's address is a rural route address, or the address is
being provided as latitude and longitude coordinates, use the street name subfield only. Street
name must be alphanumeric. A dash (-), comma (,), period (.), hash (#), slash (/), or apostrophe
(') are acceptable punctuation.
• South side of Evewaugh Lane
• RR 2 Box 18
• Lat. 38.66204 Long. 121.510265
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rev July 2021 --- California Death Registration 29
Latitude and longitude coordinates are acceptable entries and may be useful for rural areas
where a postal box is used for an address, for homeless individuals, etc.
If decedent was “Sheltered-Homeless” or “In Institution-Homeless”, use the Street
Name/Address of facility/shelter/institution. See additional options below for
recommendations for entering information on decedents experiencing homelessness at the
time of death.
Apt/Suite/Unit (optional)
This subfield may be left blank. Enter the Apt/Suite/Unit if the decedent's address included an
apartment, suite or unit number. Only alphanumeric entries are acceptable in this subfield. A
dash (-), period (.), slash (/), apostrophe ('), hash (#), comma (,), and parentheses (()) are
acceptable punctuation.
• Apt 4B
• Ste 100
What to do...
If the decedent … Then enter …
was on tour of military duty or attending
college
his or her current military or college address.
had been living in a facility for a period of
one year or longer, (e.g., group home,
mental institution, nursing home,
penitentiary, or hospital for the chronically
ill)
the address of the facility.
had been living in a facility for a period of
less than one year
the residence address where the individual lived
prior to being institutionalized.
had been living in a long-term care facility
for a period of less than one year and the
person’s prior address is unknown
the address of the facility.
was a minor child the residence address of the parent(s), legal
guardian, or custodian.
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was homeless * for Sheltered/In Institution homeless
decedents, enter the address of the institution
or shelter facility where decedent was staying at
time of death.
Sheltered Examples
Scenario A: Decedent was staying at Dare to
Care for the Homeless shelter at 4508 Atlantic
Ave Ste 186, Long Beach, CA 90807
Street
Number
Street Name Apt/Suite/Unit
4508 Atlantic Ave Ste 186
Scenario B: Decedent was staying at various
friends’ houses, couch surfing. At time of death,
friend’s address was 123 Example St Apt 1,
Sacramento, CA 95817
Street
Number
Street Name Apt/Suite/Unit
123 Example St 1
In Institution Example
Scenario C: Decedent was in a behavioral health
inpatient program at Fremont Hospital at 39001
Sundale Dr, Fremont CA 94538
Street
Number
Street Name Apt/Suite/Unit
39001 Sundale Dr (leave blank)
for Unsheltered homeless decedents, use the
latitude and longitude of the physical location
where the individual usually lived, or a
description of the physical location in the street
name.
Unsheltered Example
Scenario D: Decedent was known to stay in
park, and latitude and longitude were
obtainable
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rev July 2021 --- California Death Registration 31
Street
Number
Street Name Apt/Suite/Unit
(leave
blank)
Lat. 38.66204
Long.
121.510265
(leave blank)
Scenario E: Decedent was known to stay in
parking lot, near two cross streets
Street
Number
Street Name Apt/Suite/Unit
(leave
blank)
Parking lot at
4th and Main
Streets
(leave blank)
is unknown and no address can be
identified
If unknown, enter UNK in the street name
subfield.
* Homeless is defined as lacking a fixed, regular, and adequate nighttime residence.
Unsheltered - Lacked a fixed, regular, and adequate nighttime residence: residing in a place not
meant for human habitation.
Sheltered - Lacked a fixed, regular, and adequate nighttime residence: residing in a publicly or
privately operated shelter designated to provide temporary living arrangements. May include
congregate shelters, transitional housing, and hotels and motels paid for by charitable
organizations or by federal, state and local government programs, or “couch surfing”.
In Institution - Lacked a fixed, regular, and adequate nighttime residence: in an institution
where the decedent would have resided for 90 days or less and who resided in an emergency
shelter or place not meant for human habitation immediately before entering that institution.
Examples include:
• Foster care home or foster care group home
• Hospital or other residential non-psychiatric medical facility
• Jail, prison, or juvenile detention facility
• Long-term care facility or nursing home
• Psychiatric hospital or other psychiatric facility
• Substance abuse treatment facility or detox center
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rev July 2021 --- California Death Registration 32
21 City
Enter the name of the city, town, or location where the decedent lived. If the informant refuses
to provide the information or it is not available, enter UNK. A dash (-), period (.), or apostrophe
(') is acceptable punctuation.
The residence of the decedent is the place where their household is located. This is not
necessarily the same as the home state, voting residence, mailing address, or legal residence,
but must reflect where the decedent lives most of the time.
22 County/Province
Enter the county or province of residence associated with the decedent’s residence entries in
Fields 20 and 21. When entering a county/parish as free text, the entry must be alphabetic or a
dash (-).
What to do...
If the decedent resided … Then …
in California select the name of the California county or UNK
for unknown from the dropdown.
in a US state outside of California enter the name of the out-of-state county/parish
or UNK for unknown in the text field.
in an unknown US state EDRS will auto-populate UNK.
in a US Territory enter the name of the other-state-county or UNK
if unknown in the text field.
in a US Territory, but territory is unknown EDRS will auto-populate UNK.
in Canada EDRS will auto-populate the province selected (in
State/Province Field 25).
in Canada, but the province is unknown EDRS will auto-populate UNK.
in Mexico EDRS will auto-populate a dash (-).
in another Foreign Country EDRS will auto-populate a dash (-).
in an unknown Foreign Country EDRS will auto-populate a dash (-).
unknown EDRS will auto-populate UNK.
23 Zip Code
Enter the zip code or postal code associated with the decedent’s residence entries in Fields 20,
21 and 22.
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rev July 2021 --- California Death Registration 33
A US zip code entry must be a minimum of five digits, but a 5 digit zip code plus 4 digit
extension. US 5 digit Zip Codes may only include numbers. A dash (-) is acceptable when there is
no zip code. US 4 digit Zip Code extensions may be blank or may only include numbers.
Foreign Postal Codes must be alphanumeric. A dash (-), period (.) is acceptable punctuation.
The maximum is 9 characters. A dash (-) is acceptable when there is no postal code.
What to do...
If the decedent resided … Then …
in a US state or US Territory enter a 5 digit zip code. A dash (-) is acceptable when there is
no zip code. The 4 digit zip code extension is optional.
in Canada, Mexico, or Other
Foreign Country
you may enter a foreign postal code up to 9 characters, if
known. Enter a dash (-) if a foreign postal code is not available.
in an unknown zip code enter a dash (-).
24 Years in County
Enter the total number of years the decedent lived in the county/province listed in Field 22.
Years in County must be numeric, UNK if unknown, or a dash (-) if no information is available.
Round the entry to the nearest full year, unless it would make the number of years in the
county/province exceed the decedent's age.
What to do...
If … And years in county/province is … Then enter …
US State/US Territory/Canada less than 12 months 0.
US State/US Territory/Canada years Enter the number of
years.
US State/US Territory/Canada unknown UNK.
Mexico/Other
Country/unknown address type not applicable a dash (-).
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rev July 2021 --- California Death Registration 34
25 State/Foreign Country
Select the appropriate address type from the dropdown in Field 25. The available options are:
• US State
• US Territory
• Canadian Province
• Mexican State
• Other Country
• Other Country UNK
• Unknown
After an address type has been designated, a subsequent field will populate, requesting further
details regarding the state/foreign country.
What to do...
If … Then select…
US State US State from the dropdown. Then select the appropriate state from the
dropdown. The US state abbreviation will print on the death certificate.
US Territory
US Territory from the dropdown. Then select the appropriate territory
from the dropdown. The US territory abbreviation will print on the death
certificate.
Canadian
Province
Canadian Province from the dropdown. Then select the appropriate
province from the dropdown. The Canadian province abbreviation and
CN will print on the death certificate.
Mexican State
Mexican State from the dropdown. Then select the appropriate state
from the dropdown. The Mexican state abbreviation and MX will print on
the death certificate.
Other Country
Other Country from the dropdown. Then use the reference browser
(click on the magnifying glass icon) to select the foreign country. EDRS
will populate the foreign country or foreign country abbreviation.
unknown US
State
US State from the dropdown. Then select UNK from the dropdown. UNK
will print on the death certificate.
unknown US
Territory
US Territory from the dropdown. Then select Unknown from the
dropdown. UNK will print on the death certificate.
unknown
Canadian
Province
Canadian Province from the dropdown. Then select Unknown from the
dropdown. UNK, CN will print on the death certificate. Alternatively, you
may leave the Canadian Province dropdown unselected (double dash)
and CN will print.
unknown
Mexican State
Mexican State from the dropdown. Then select Unknown from the
dropdown. UNK, MX will print on the death certificate. Alternatively, you
may leave the Mexican state dropdown unselected (double dash) and
MX will print on the death certificate.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 35
unknown Other
Foreign Country
Other Country UNK from the dropdown. No further action is needed.
FRN-UNK will print on the death certificate.
Unknown Unknown from the dropdown. No further action is needed. UNK will
print on the death certificate.
25A Homeless Checkbox
Determining if a Decedent May Have Been Experiencing Homelessness
The following table can be used to determine if an individual was experiencing homelessness at
time of death.
Enter whether the decedent was homeless at the time of death as appropriate from the list of
options.
Homeless is defined as lacking a fixed, regular, and adequate nighttime residence and can
either be Sheltered, Unsheltered, or In Institution
Select…. When…
‘Yes’
the decedent was homeless at time of death
(can be unsheltered, sheltered, or in
institution from HUD definition of literally
homeless)
‘No’
the decedent was not homeless at time of
death
UNK or ‘Unknown’
it remains unknown whether decedent was
homeless at time of death, despite
investigation and informant report.
If YES is selected in 25A, another field will appear with drop-down options. Select option that
best describes homeless status of decedent at the time of death.
Category Select in Field Definition/Criteria
Unsheltered
Homeless
“Unsheltered”
Lacked a fixed, regular, and adequate nighttime
residence: residing in place not meant for human
habitation.
Sheltered
Homeless
“Sheltered”
Lacked a fixed, regular, and adequate nighttime
residence: residing in a publicly or privately operated
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 36
Category Select in Field Definition/Criteria
shelter designated to provide temporary living
arrangements. May include congregate shelters,
transitional housing, and hotels and motels paid for by
charitable organizations or by federal, state and local
government programs, or “couch surfing”.
In Institution
“In
Institution”
Lacked a fixed, regular, and adequate nighttime
residence: in an institution where the decedent would
have resided for 90 days or less and who resided in an
emergency shelter or place not meant for human
habitation immediately before entering that institution.
Examples include:
• Foster care home or foster care group home
• Hospital or other residential non-psychiatric
medical facility
• Jail, prison, or juvenile detention facility
• Long-term care facility or nursing home
• Psychiatric hospital or other psychiatric facility
• Substance abuse treatment facility or detox
center
26 Informant Name and Relationship
Informant Relationship
The informant is the person providing the personal data about the decedent. Select the blood,
legal, or other relationship of the informant to the deceased from the dropdown. Informant's
Relationship must be alphabetic. A dash (-) is acceptable punctuation. The available options are
as follows:
• Husband
• SRDP
• Spouse
• Wife
• Father
• Mother
• Brother
• Daughter
• Friend
• Granddaughter
• Grandson
• Neighbor
• Sister
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 37
• Son
• Other
If OTHER is selected, a subsequent text field will populate. Enter the desired relationship type
as provided by the informant in this field. Avoid derogatory or nonsensical entries.
Informant Name
Enter the first, middle and last names of the informant in the appropriate fields. Names must
be alphabetic. A dash (-), period (.), or apostrophe (') is acceptable punctuation.
• First Name
• Middle Name
• Last Name
Suffix
Select the appropriate suffix for the informant from the dropdown. If the informant does not
have a suffix, this field may be left as a double dash (--).
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 38
What to do...
If … Then enter …
the informant has only one name the name in the last name field and enter a
dash (-) in first and middle name fields.
this is a pending medical examiner/coroner’s
case and no informant has been located medical examiner/coroner's name.
this is a pending medical examiner/coroner’s
case and an informant is identified later
the informant’s name may be added later via
an amendment form (VS 24).
this is a public administrator’s case, where
the public administrator is listed as the
original informant, and informant is
identified later
the informant’s name may be added later via
an amendment form (VS 24).
a pre-need contract was provided by the
deceased prior to death
the name of the person designated by the
decedent to handle the disposition.
pre-need is entered erroneously
the survivors may provide a copy of the
erroneous certificate of death (that indicates
he/she pre-deceased the decedent on
record) to amend the death certificate.
27 Informant Mailing Address
Enter the informant’s mailing address in Field 27.
There are seven subfields within Field 27:
• Mailing Address Type
• State/Province
• Street Number
• Street Name
• Apt/Suite/Unit (Optional)
• City
• Zip Code
This address may be a post office box number. The information is used to contact the informant
to request missing and/or additional information.
Mailing Address Type
Select the appropriate address type from the dropdown in Field 27. The available options are:
• US State
• US Territory
• Canadian Province
• Mexican State
• Other Country
• Other Country UNK
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 39
• Unknown
After an address type has been designated, a subsequent field will populate, requesting further
details regarding the state/foreign country.
What to do...
If … Then select…
US State US State from the dropdown. Then select the appropriate state from
the dropdown. The US state abbreviation will print on the death
certificate.
US Territory US Territory from the dropdown. Then select the appropriate
territory from the dropdown. The US territory abbreviation will print
on the death certificate.
Canadian Province Canadian Province from the dropdown. Then select the appropriate
province from the dropdown. The Canadian province abbreviation
and CN will print on the death certificate.
Mexican State Mexican State from the dropdown. Then select the appropriate state
from the dropdown. The Mexican state abbreviation and MX will print
on the death certificate.
Other Country Other Country from the dropdown. Then use the reference browser
(click on the magnifying glass icon) to select the foreign country. EDRS
will populate the foreign country or foreign country abbreviation.
unknown US State US State from the dropdown. Then select UNK from the dropdown.
UNK will print on the death certificate.
unknown US
Territory
US Territory from the dropdown. Then select Unknown from the
dropdown. UNK will print on the death certificate.
unknown Canadian
Province
Canadian Province from the dropdown. Then select Unknown from
the dropdown. UNK, CN will print on the death certificate.
Alternatively, you may leave the Canadian Province dropdown
unselected (double dash) and CN will print.
unknown Mexican
State
Mexican State from the dropdown. Then select Unknown from the
dropdown. UNK, MX will print on the death certificate. Alternatively,
you may leave the Mexican state dropdown unselected (double dash)
and MX will print on the death certificate.
unknown Other
Foreign Country
Other Country UNK from the dropdown. No further action is needed.
FRN-UNK will print on the death certificate.
Unknown Unknown from the dropdown. No further action is needed. UNK will
print on the death certificate.
Street Number (optional)
This subfield may be left blank. Enter the Street number if the informant’s address included a
street number. Street number must be alphanumeric. A dash (-), period (.), slash (/), or
apostrophe (') are acceptable punctuation.
• 123
• 123B
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 40
Street Name (required)
Enter the street name of the informant’s address. If the informant’s address is a rural route
address, or the address is being provided as latitude and longitude coordinates, use the street
name subfield only. Street name must be alphanumeric. A dash (-), comma (,), period (.), hash
(#), slash (/), or apostrophe (') are acceptable punctuation.
• South side of Evewaugh Lane
• RR 2 Box 18
• Lat. 38.66204 Long. 121.510265
Latitude and longitude coordinates are acceptable entries and may be useful for rural areas
where a postal box is used for an address, for homeless individuals, etc.
Apt/Suite/Unit (optional)
This subfield is optional and may be left blank. Enter the Apt/Suite/Unit if the informant’s
address included an apartment, suite, or unit number. Only alphanumeric entries are
acceptable in this subfield. A dash (-), period (.), slash (/), apostrophe ('), hash (#), comma (,),
and parentheses (()) are acceptable punctuation.
• Apt 4B
• Ste 100
City
Enter the name of the city associated with the informant’s mailing address. City must be
alphanumeric. A dash (-), period (.), or apostrophe (') is acceptable punctuation.
Zip Code
Enter the informant’s zip code or postal code associated with the informant’s mailing address.
A US zip code entry must be a minimum of five digits, but a 5 digit zip code plus 4 digit
extension. US 5 digit Zip Codes may only include numbers. A dash (-) is acceptable when there is
no zip code. US 4 digit Zip Code extensions may be blank or may only include numbers.
Foreign Postal Codes must be alphanumeric. A dash (-) or period (.) is acceptable punctuation.
The maximum is 9 characters. A dash (-) is acceptable when there is no postal code.
If address information is not available, a dash(s) is acceptable.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 41
28, 29, & 30 Name of Surviving Spouse/SRDP
Enter the Surviving Spouse/SRDP names at birth in the appropriate fields.
• 28 First
• 29 Middle
• 30 Last (Birth) Name
Spouse name Fields 28, 29 and 30 depends on the marital status selected in Field 12. Names
must be alphabetic. A dash (-), period (.), or apostrophe (') is acceptable punctuation.
Suffix
Select the appropriate suffix for the spouse from the dropdown. If the spouse does not have a
suffix, this field may be left as a double dash (--).
What to do...
If … Then enter…
the decedent was married or
in a SRDP at the time of death the name of the surviving spouse/SRDP.
there is no surviving
spouse/SRDP a dash (-) in Field 28 and Field 29 and Field 30.
the spouse/SRDP dies
simultaneously
the name of the spouse/SRDP in Field 28 and Field 29 and
Field 30. Also select Married/Wid or SRDP/SURV in Field 12.
the surviving spouse/SRDP
only has one name a dash (-) in Field 28 and Field 29 and the name in Field 30.
What to do...
If Field 12 is … Then Fields 28, 29, 30 …
Never Married a dash (-) is auto-populated and spouse fields are not editable.
Married enter the spouse's name in Fields 28, 29 and 30. If spouse's name is not
available, enter dash(es) (-) as appropriate.
Widowed a dash (-) is auto-populated and spouse fields are not editable.
Divorced a dash (-) is auto-populated and spouse fields are not editable.
Married/Wid enter the spouse's name in Fields 28, 29 and 30. If spouse's name is not
available, enter dash(es) (-) as appropriate.
SRDP enter the SRDP's name in Fields 28, 29 and 30.
SRDP SURV enter a dash (-) in Fields 28, 29 and 30.
SRDP/SURV enter the partner's name in Fields 28, 29 and 30. If partner's name is not
available, enter dash(es) (-) as appropriate.
UNKNOWN enter a dash (-) in Fields 28, 29 and 30.
If marital status is amended, spouse fields (Fields 28, 29, 30) may also need to be amended.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 42
31, 32, & 33 Father/Parent’s Legal Names
Enter the Father/Parent’s legal names in the appropriate fields. Names must be alphabetic. A
dash (-), period (.), or apostrophe (') is acceptable punctuation. Withheld is not an option.
• 31 First
• 32 Middle
• 33 Last
Legal names for purposes of vital records are those acquired through birth, adoption, court-
ordered name change, marriage, or naturalization.
Suffix
Select the appropriate suffix for the father/parent from the dropdown. If the father/parent
does not have a suffix, this field may be left as a double dash (--).
What to do...
If … Then enter…
the father/parent does not have a
middle name a dash (-) in Field 32.
the father/parent has long or
multiple names and additional
space is necessary
as many characters as permitted by available space. If
additional space is needed, submit an Affidavit to
Amend a Record (VS 24e) to record the full legal name.
the father/parent has only one
name
a dash (-) in Field 31 and Field 32 and the name in
Field 33.
the father’s/parent’s first, middle or
last name is unknown UNKNOWN or UNK in the appropriate field.
there is no father listed on the
decedent’s birth certificate a dash (-) in Fields 31-34 is acceptable
34 Father/Parent’s Birth State or Foreign Country
Select the appropriate birth place address type from the dropdown in Field 34. The available
options are:
• US State
• US Territory
• Canadian Province
• Mexican State
• Other Country
• Other Country UNK
• Unknown
After an address type has been designated, a subsequent field will populate, requesting further
details regarding the birth state/foreign country.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 43
What to do...
If … Then select…
US State
US State from the dropdown. Then select the appropriate state from
the dropdown. The US state abbreviation will print on the death
certificate.
US Territory
US Territory from the dropdown. Then select the appropriate
territory from the dropdown. The US territory abbreviation will print
on the death certificate.
Canadian Province
Canadian Province from the dropdown. Then select the appropriate
province from the dropdown. The Canadian province abbreviation
and CN will print on the death certificate.
Mexican State
Mexican State from the dropdown. Then select the appropriate state
from the dropdown. The Mexican state abbreviation and MX will print
on the death certificate.
Other Country
Other Country from the dropdown. Then use the reference browser
(click on the magnifying glass icon) to select the foreign country. EDRS
will populate the foreign country or foreign country abbreviation.
unknown US State US State from the dropdown. Then select UNK from the dropdown.
UNK will print on the death certificate.
unknown US
Territory
US Territory from the dropdown. Then select Unknown from the
dropdown. UNK will print on the death certificate.
unknown Canadian
Province
Canadian Province from the dropdown. Then select Unknown from
the dropdown. UNK, CN will print on the death certificate.
Alternatively, you may leave the Canadian Province dropdown
unselected (double dash) and CN will print.
unknown Mexican
State
Mexican State from the dropdown. Then select Unknown from the
dropdown. UNK, MX will print on the death certificate. Alternatively,
you may leave the Mexican state dropdown unselected (double dash)
and MX will print on the death certificate.
unknown Other
Foreign Country
Other Country UNK from the dropdown. No further action is needed.
FRN-UNK will print on the death certificate.
Unknown Unknown from the dropdown. No further action is needed. UNK will
print on the death certificate.
born on the high
seas
Other Country UNK. No further action is needed. FRN-UNK will print
on the death certificate.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 44
35, 36, & 37 Mother/Parent’s Legal Birth Names
Enter the Mother/Parent’s legal names in the appropriate fields. Names must be alphabetic. A
dash (-), period (.), or apostrophe (') is acceptable punctuation. Withheld is not an option.
• 35 First
• 36 Middle
• 37 Last (Birth) Name
Definition: Birth name is the parent’s name prior to any marriages.
Legal names for purposes of vital records are those acquired through birth, adoption, court-
ordered name change, or naturalization.
Suffix
Select the appropriate suffix for the mother/parent from the dropdown. If the mother/parent
does not have a suffix, this field may be left as a double dash (--).
What to do...
If … Then enter…
the mother/parent does not have a
middle name a dash (-) in Field 36.
the mother/parent has long or
multiple names and additional
space is necessary
as many characters as permitted by available space. If
additional space is needed, submit an Affidavit to
Amend a Record (VS 24e) to record the full legal name.
the mother/parent has only one
name
a dash (-) in Field 35 and Field 36 and the name in
Field 37.
the mother’s/parent’s first, middle
or last name is unknown
UNKNOWN or UNK in the appropriate field.
38 Mother/Parent’s Birth State or Foreign Country
Select the appropriate birth place address type from the dropdown in Field 38. The available
options are:
• US State
• US Territory
• Canadian Province
• Mexican State
• Other Country
• Other Country UNK
• Unknown
After an address type has been designated, a subsequent field will populate, requesting further
details regarding the birth state/foreign country.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 45
What to do...
If … Then select…
US State
US State from the dropdown. Then select the appropriate state from
the dropdown. The US state abbreviation will print on the death
certificate.
US Territory
US Territory from the dropdown. Then select the appropriate
territory from the dropdown. The US territory abbreviation will print
on the death certificate.
Canadian Province
Canadian Province from the dropdown. Then select the appropriate
province from the dropdown. The Canadian province abbreviation
and CN will print on the death certificate.
Mexican State
Mexican State from the dropdown. Then select the appropriate state
from the dropdown. The Mexican state abbreviation and MX will print
on the death certificate.
Other Country
Other Country from the dropdown. Then use the reference browser
(click on the magnifying glass icon) to select the foreign country. EDRS
will populate the foreign country or foreign country abbreviation.
unknown US State US State from the dropdown. Then select UNK from the dropdown.
UNK will print on the death certificate.
unknown US
Territory
US Territory from the dropdown. Then select Unknown from the
dropdown. UNK will print on the death certificate.
unknown Canadian
Province
Canadian Province from the dropdown. Then select Unknown from
the dropdown. UNK, CN will print on the death certificate.
Alternatively, you may leave the Canadian Province dropdown
unselected (double dash) and CN will print.
unknown Mexican
State
Mexican State from the dropdown. Then select Unknown from the
dropdown. UNK, MX will print on the death certificate. Alternatively,
you may leave the Mexican state dropdown unselected (double dash)
and MX will print on the death certificate.
unknown Other
Foreign Country
Other Country UNK from the dropdown. No further action is needed.
FRN-UNK will print on the death certificate.
Unknown Unknown from the dropdown. No further action is needed. UNK will
print on the death certificate.
born on the high
seas
Other Country UNK. No further action is needed. FRN-UNK will print
on the death certificate.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 46
39 Date of Disposition
DO NOT leave this field blank.
Select the date the disposition will take place from the calendar tool or enter the date in
MM/DD/YYYY format.
What to do...
If … Then enter …
the remains are to be removed
from California
the date the remains will be shipped out of California
jurisdiction.
the remains are to be used for
scientific or medical research
the date the remains will be accepted by the facility or
curator.
the remains are to be cremated the date to be cremated.
the remains are to be cremated
and shipped to another location
the date of cremation. Only the date of cremation is
necessary to file the death certificate and obtain a
permit. The certificate must be amended if the date of
cremation changes or the cremation did not occur.
the remains are to be cremated
and buried the date of cremation.
the remains are put into
temporary storage the date stored.
the death is a medical
examiner/coroner’s case and
final disposition is pending
a dash (-).
buried (land or sea) the date buried.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 47
40 Place of Final Disposition
Information in this field should reflect the place of final disposition. You may enter both a
name/description and an address. At minimum, name/description or a complete address is
required. A complete address includes street name, city, state, and zip code.
The place of disposition is an address sufficient to identify the final place of disposition. It may
include any of the following:
• latitude (enter appropriate degree) and longitude (enter appropriate degree) for burial
at sea or scattering of cremains
• location where the remains are to be shipped if removed from California
• facility address if the body is donated for scientific use
• cemetery address if the remains are buried. Cemetery means any one, or a combination
of more than one of the following in a place used, or intended to be used, and dedicated
for cemetery purposes:
o a burial park (cemetery), for earth interment
o a mausoleum, for crypt or vault interment
o a columbarium for cinerary interment
REFERENCE: Health and Safety Code Section 7003
There are eight subfields within Field 40:
• Place of Final Disposition Name or Description
• Address Type
• State/Province
• Street Number
• Street Name
• Apt/Suite/Unit
• City
• Zip Code
Place of Final Disposition Name or Description
Enter the name of the facility, or person controlling the cremains.
Place of Final Disposition Name or Description must be alphanumeric. A dash (-), period (.),
comma (,), colon (:), semicolon (;), apostrophe ('), forward slash (/), or ampersand (&) are
acceptable punctuation.
Address Type
Select the appropriate address type for the place of final disposition from the dropdown in Field
40. The available options are:
• US State
• US Territory
• Canadian Province
• Mexican State
• Other Country
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 48
• Other Country UNK
• Unknown
After an address type has been designated, a subsequent field will populate, requesting further
details regarding the place of final disposition.
What to do...
If … Then select…
US State
US State from the dropdown. Then select the appropriate state from
the dropdown. The US state abbreviation will print on the death
certificate.
US Territory
US Territory from the dropdown. Then select the appropriate
territory from the dropdown. The US territory abbreviation will print
on the death certificate.
Canadian Province
Canadian Province from the dropdown. Then select the appropriate
province from the dropdown. The Canadian province abbreviation
and CN will print on the death certificate.
Mexican State
Mexican State from the dropdown. Then select the appropriate state
from the dropdown. The Mexican state abbreviation and MX will print
on the death certificate.
Other Country
Other Country from the dropdown. Then use the reference browser
(click on the magnifying glass icon) to select the foreign country. EDRS
will populate the foreign country or foreign country abbreviation.
unknown US State US State from the dropdown. Then select UNK from the dropdown.
UNK will print on the death certificate.
unknown US
Territory
US Territory from the dropdown. Then select Unknown from the
dropdown. UNK will print on the death certificate.
unknown Canadian
Province
Canadian Province from the dropdown. Then select Unknown from
the dropdown. UNK, CN will print on the death certificate.
Alternatively, you may leave the Canadian Province dropdown
unselected (double dash) and CN will print.
unknown Mexican
State
Mexican State from the dropdown. Then select Unknown from the
dropdown. UNK, MX will print on the death certificate. Alternatively,
you may leave the Mexican state dropdown unselected (double dash)
and MX will print on the death certificate.
unknown Other
Foreign Country
Other Country UNK from the dropdown. No further action is needed.
FRN-UNK will print on the death certificate.
Unknown Unknown from the dropdown. No further action is needed. UNK will
print on the death certificate.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 49
Street Number (optional)
This subfield may be left blank. Enter the Street number if the place of final disposition included
a street number. Street number must be alphanumeric. A dash (-), period (.), slash (/), or
apostrophe (') are acceptable punctuation.
• 123
• 123B
Street Name (required)
Enter the street name for the place of final disposition. If the place of final disposition is a rural
route address, or the address is being provided as latitude and longitude coordinates, use the
street name subfield only. Street name must be alphanumeric. A dash (-), comma (,), period (.),
hash (#), slash (/), or apostrophe (') are acceptable punctuation.
• South side of Evewaugh Lane
• RR 2 Box 18
• Lat. 38.66204 Long. 121.510265
Latitude and longitude coordinates are acceptable entries and may be useful for rural areas
where a postal box is used.
A post office box address is not acceptable.
Apt/Suite/Unit (optional)
This subfield and may be left blank. Enter the Apt/Suite/Unit if the place of final disposition
includes an apartment, suite, or unit number. Only alphanumeric entries are acceptable in this
subfield. A dash (-), period (.), slash (/), apostrophe ('), hash (#), comma (,), and parentheses (())
are acceptable punctuation.
• Apt 4B
• Ste 100
City
Enter the name of the city associated with the place of final disposition. City must be
alphanumeric. A dash (-), period (.), or apostrophe (') is acceptable punctuation.
Zip Code
Enter the zip code or postal code associated with the place of final disposition.
A US zip code entry must be a minimum of five digits, but a 5 digit zip code plus 4 digit
extension. US 5 digit Zip Codes may only include numbers. A dash (-) is acceptable when there is
no zip code. US 4 digit Zip Code extensions may be blank or may only include numbers.
Foreign Postal Codes must be alphanumeric. A dash (-) or period (.) is acceptable punctuation.
The maximum is 9 characters. A dash (-) is acceptable when there is no postal code.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 50
What to do...
If … Then enter…
the cremated remains are to be scattered at
sea off the California coast, in a cemetery
rose garden, or on private property (with the
written permission of the property owner)
a description/address to identify the district
of disposition, e.g., At Sea Off the Coast of
Marin County; or Forest Lawn Cemetery,
Point Reyes, CA 94956.
scattering is to be done in another State the location or address of the scattering.
the cremated remains are to be returned to
the family
RESIDENCE: or RES: and the person’s name
and complete address (street name and
number, city, state, and zip code).
the cremated remains are to be disposed of
in more than one location, e.g. retained by
two or more family members at separate
locations
the address/location associated with the
person with authority to dispose of the
cremains. A permit must be purchased for
each location if the cremains are disposed of
in more than one location, even when only
one address/location is listed on the
certificate.
the cremated remains are being shipped to a
mortuary outside of California for a family
member residing out-of-state and the
address is unknown
the name and address of the out-of-state
mortuary or person assuming control of the
remains.
the body is donated for scientific use the name and address of the facility.
the remains will be temporarily stored the facility address.
the death is a pending medical
examiner/coroner’s case a dash (-).
the body is to be disposed of by burial at sea enter the appropriate latitude and longitude.
41 Type of Disposition(s)
Select the type of disposition, or combination of dispositions, from the EDRS dropdown. Choose
the selection that includes all intended dispositions, including those that are out-of-state, in the
order that they are to occur. Death certificates must be amended to reflect any change in type
of disposition.
REFERENCE: Health and Safety Code Sections 7001 through 7025.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 51
Authorized dispositions
TRANSIT is only used when the remains/cremains are to be transported out of California.
Type of Disposition
(Dropdown)
Definition Printed on DP and
DC output
Alkaline Hydrolysis Alkaline hydrolysis is a process that uses water,
alkalinity, and heat to reduce a body to its final
mineral bone remains.
ALKALINE
HYDROLYSIS
Burial Burial in a cemetery, interment, entombment,
cryogenic suspension.
BURIAL
Burial at Sea Burial of whole bodies at sea as permitted by
specific state and federal laws.
BURIAL AT SEA
Cremated in California
/Transit/ Scatter
Cremation, followed by transit out of state for
scattering of cremains at sea or over land.
CREMATE/TRANSIT
/SCATTER
Cremation Cremation, when none of the other cremation
categories apply or more than one of the other
cremation categories apply.
CREMATION
Cremation/Burial Cremation, followed by burial of the cremains. CREMATE/BURIAL
Cremation/ Religious
Shrine
Cremation, followed by placement of the
cremains in a religious shrine or church**
location.
CREMATE/
RELIGIOUS SHRINE
Cremation/ Residence Cremation, followed by placement of the
cremains in one or more family residences.
CREMATE/
RESIDENCE
Cremation/Scattering
Ashes Over Land
Cremation, followed by scattering ashes over
private or public property in California*
CREMATE/SCATTER
ON LAND
Cremation/ Scattering
at Sea
Cremation, followed by scattering of ashes at sea
500 yards or more off the coast of California.
CREMATE/SCATTER
AT SEA
Cremation/Transit/
Burial
Cremation, followed by transit out of State for
Burial.
CREMATE/TRANSIT
/BURIAL
Cremation/Transit/
Religious Shrine
Cremation, followed by transit out of State for
placement in a religious shrine or church**
location.
CREMATE/TRANSIT
/RELIGIOUS SHRINE
Cremation/Transit/
Residence
Cremation, followed by transit out of State for
placement in a Residence.
CREMATE/TRANSIT
/RESIDENCE
Pending Coroner's
Investigation
Remains are held pending a Coroner's
investigation. A subsequent Disposition Permit
will be needed.
PENDING CORONER
INVESTIGATION
Religious Shrine Placement in a religious shrine or church**
location.
RELIGIOUS SHRINE
Scientific Use A decedent’s entire body is donated for medical
research under the Uniform Anatomical Gift
Act***
SCIENTIFIC USE
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 52
Type of Disposition
(Dropdown)
Definition Printed on DP and
DC output
Temporary
Envaultment
Remains are envaulted pending further
disposition decisions. A subsequent Disposition
Permit will be needed. Does not include
Coroner's cases.
TEMPORARY
ENVAULTMENT
Transit Shipping remains or cremated remains out of
California, usually to a mortuary or crematory.
Subsequent disposition will occur in the new
location.
TRANSIT
Transit/Burial Shipping remains out of State for Burial. TRANSIT/BURIAL
Transit/Cremated
outside of
California/Scattered at
Sea
The decedent's body is shipped out of State for
cremation followed by scattering ashes at sea.
Final details are handled under the laws of the
destination state or country.
TRANSIT/
CREMATE/
SCATTER
Transit/Cremation/
Burial
The decedent's body is shipped out of State for
cremation followed by burial. Final details are
handled under the laws of the destination state
or country.
TRANSIT/
CREMATE/ BURIAL
Transit/Cremation/
Religious Shrine
The decedent's body is shipped out of State for
cremation followed by placement of the
cremains in a religious shrine or church. Final
details are handled under the laws of the
destination state or country.
TRANSIT/
CREMATE/
RELIGIOUS SHRINE
Transit/Cremation/
Residence
The decedent's body is shipped out of State for
cremation followed by placement of the
cremains in one or more residences. Final details
are handled under the laws of the destination
state or country.
TRANSIT/
CREMATE/
RESIDENCE
Transit/Religious
Shrine
The decedent's remains are shipped out of State
for placement in a religious shrine or church.
Final details are handled under the laws of the
destination state or country.
TRANSIT/
RELIGIOUS SHRINE
Transit/Scientific A decedent’s entire body is donated for medical
research under the Uniform Anatomical Gift
Act*** and is Transported out of State to the
scientific institution.
TRANSIT/
SCIENTIFIC USE
*Scattering over land generally requires written permission of the land owner. Legal
requirements governing public land should be researched.
**Cremated remains may be kept in a church or religious shrine upon written permission from
the religious shrine and if no conflict exists with local use permit requirements or zoning laws.
***When the disposition is for Scientific Use, only an officer of a duly accredited medical
college or a funeral director may remove a body from one registration district to another
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 53
prior to filing a death certificate and obtaining a permit. The death certificate must be filed
and the permit obtained within the eight-day mandate.
REFERENCE: Health and Safety Code Section 102775.
42 and 43 Signature of Embalmer and Embalmer's License Number
Utilize the dropdown in Field 42 to designate whether or not the decedent was embalmed.
If the decedent was not embalmed, select NO from the dropdown. EDRS will automatically
populate NOT EMBALMED in the Signature of Embalmer Last Name subfield and a dash (-) in
Field 43 (Embalmer’s License Number).
If the decedent was embalmed, select YES from the dropdown. Utilize the magnifying glass icon
adjacent to First Name in Field 42 to access the Embalmer Browser. Search for the embalmer by
first name, last name or license number. Select the desired embalmer to auto-populate Fields
42 and 43.
If the embalmer cannot be located within the Embalmer Browser, manually enter the
embalmer's information into the appropriate fields.
Names must be alphabetic. A dash (-), period (.), or apostrophe (') is acceptable punctuation. If
the embalmer does not have a first or middle name, enter a dash (-). The dash will not print on
the certificate.
Embalmer License Number must be EMB followed by a number. No spaces, hyphen or other
punctuation.
REFERENCE: Health and Safety Code Section 102805 and Business and Professions Code 7649
What to do...
If … Then …
the body is later embalmed use a VS 24 (Affidavit to Amend a Record) to add the printed
or typed name and license number of the embalmer.
Embalmer's certification
The embalmer or authorized agent must electronically attest the certificate if Fields 42 and 43
indicate embalming has occurred.
Once the embalmer or authorized agent electronically attests to the certificate, Fields 42 and
43 are locked and no changes may be made. If an error in either Field 42 or 43 is discovered
prior to registration, the FD tab can be unlocked to remove the embalmer name. If an error is
discovered after registration, changing or deleting an embalmer certification requires an
amendment under the direction of a court order.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 54
44 Name of Funeral Establishment
Utilize the magnifying glass icon adjacent to Field 44 to access the Funeral Director Browser.
Search for the funeral establishment by name or license number. Select the desired funeral
establishment to auto-populate Fields 44 and 45. If the funeral establishment cannot be located
within the Funeral Director Browser, manually enter the information into the appropriate fields.
Funeral Establishment Name must be alphabetic. A dash (-), period (.), apostrophe ('), or
ampersand (&) is acceptable punctuation.
Abbreviations in the funeral establishment name must allow for unambiguous identification of
the funeral establishment.
If a family member, friend, or acquaintance is personally handling the California disposition or
transportation of the decedent, enter the person’s name in Field 44.
Licensing requirements
Funeral businesses and directors not licensed in California cannot conduct business or hire an
unlicensed representative to conduct business within California.
Transport companies, removal services and other similar entities, are not permitted to conduct
funerary business for firms not licensed by the State of California.
Coroners/medical examiners, state-appointed curators, cryonic facilities, etc., are not required
to hold a funerary license.
45 Funeral Establishment License Number
Utilize the magnifying glass icon adjacent to Field 45 to access the Funeral Director Browser.
Search for the funeral establishment by name or license number. Select the desired funeral
establishment to auto-populate Fields 44 and 45. If the funeral establishment cannot be located
within the Funeral Director Browser, manually enter the information into the appropriate fields.
Funeral Establishment License Number must be FD followed by a number. No spaces, hyphen or
other punctuation. NONE is acceptable when no Funeral Home is involved.
The number entered in Field 45 should be that of the funeral establishment, not the funeral
director.
If the decedent's relative, friend, or acquaintance is personally handling the California
disposition or transportation of the decedent, enter the word NONE in Field 45.
REFERENCE: Business and Professions Code Section 7616
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46 Signature of Local Registrar
The local registrar shall review each death certificate for accuracy and completeness. If the
certificate is acceptable, the certificate is locally registered (STATUS = SUBM SR). At this time,
Field 46 (Signature of Local Registrar), Field 47 (Date Registered) and the Local Registration
Number are assigned to the certificate. If the certificate is not acceptable, the certificate is
returned to the funeral establishment for correction (STATUS = INC).
Upon local registration, corrections or additions can only be made via the amendment process.
For specific information regarding amendment procedures, refer to the Amendment Section of
the handbook.
REFERENCE: Health and Safety Code Sections 102140 and 102305
47 Registration Date
The local registrar shall review each death certificate for accuracy and completeness. If the
certificate is acceptable, the certificate is locally registered (STATUS = SUBM SR). At this time,
Field 46 (Signature of Local Registrar), Field 47 (Date Registered) and the Local Registration
Number are assigned to the certificate. If the certificate is not acceptable, the certificate is
returned to the funeral director for correction (STATUS = INC).
REFERENCE: Health and Safety Code Section 103550
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rev July 2021 --- California Death Registration 56
Place of Death (Fields 101-106)
101 Place of Death
Enter the hospital, facility, or other location where the event occurred.
Use the browser in Field 105 to select the hospital or facility for the following:
• DOA or ER/OP or IP was selected in Field 102/103
• If Hospice was selected in Field 102/103
• If Nursing Home/LTC was selected in Field 102/103
Selecting the facility for one of the options will auto-populate Field 101 and all subfields of
Fields 105 and 106.
If DECEDENT’S HOME was selected in Field 102/103, the text RESIDENCE will auto-populate
Field 101 and the decedent’s address will auto-populate all subfields of Field 105, or you can
manually enter an address.
If a family residence is indicated in this item, the relationship to the deceased should be
specified, e.g., residence; wife's residence; daughter's residence; son's residence, etc. The name
of the family member does not have to be indicated.
If OTHER was selected in Field 102/103, and the event occurred in any location not described
above, for example a park, or a mall, hotel, etc., manually enter a description of the place of
death in Field 101 and the address in all subfields of Field 105. If the body was found, that fact
should be specified.
Acceptable Entries:
• Latitude and longitude coordinates
• Descriptive terms such as a geographic location, e.g., Mojave Desert; under 3rd Street
Bridge; Balboa Park, etc.
Place of Death must be alphanumeric. A dash (-), period (.), or apostrophe (') is acceptable
punctuation.
In the event a facility name or address has changed or is no longer correct, contact the Death
Registration Help Desk at (916) 552-8123 or EDRSHelp@cdph.ca.gov.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 57
DEATHS OCCURRING IN TRANSIT
What to do...
If the death
occurred …
Then in
Field
Enter …
in an airplane 101 airplane.
104 the county/jurisdiction having jurisdiction over the city where
the airport of destination is located.
105 en route to (destination). Specify latitude (Lat.) and Longitude
(Long.) coordinates.
106 the city where the airport of destination is located.
on a ship at sea 101 ship.
104 the county/jurisdiction having jurisdiction over the city where
the port of call (City) is located.
105 en route to (destination). Specify latitude (Lat.) and Longitude
(Long.) coordinates.
106 Port of Call (City).
in a bus, car, train,
or ambulance 101 bus, car, train, or ambulance, as appropriate.
104 the county/jurisdiction where the death occurred or the first
stop.
105
indicate the nearest cross streets or position on highway (e.g. x
miles east on US 40). Latitude (Lat.) and Longitude (Long.)
coordinates acceptable.
106 the city.
in an
unincorporated
and/or rural area
101 describe the place of death.
104 the county/jurisdiction where the death occurred.
105 a geographic description. Latitude (Lat.) and Longitude (Long.)
coordinates acceptable.
106 the name of the closest city or town within the district of death,
preceded by "Rural" (e.g., Rural "Metro Town").
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102 & 103 If Hospital, Specify One/If Other Than Hospital, Specify One
Fields 102 and 103 are combined into one dropdown. Select one option only for the type of
facility or residence in which the event occurred.
If the death occurred or was pronounced in a licensed acute care hospital, make the
appropriate selection from the dropdown. The available options are:
Licensed Acute-Care Hospital Deaths
• DOA – dead on arrival
• ER/OP – emergency room or outpatient
• IP – inpatient
Other Than Hospital Deaths
• DECEDENT'S HOME
• HOSPICE – a home providing care for the sick or terminally ill.
• NURSING HOME/LTC (LTC = Long Term Care) – a home/facility providing care for the
sick/terminally ill, rehabilitative/restorative, and/or ongoing skilled nursing care to
patients/residents in need of assistance with activities of daily living.
• OTHER– none of the above responses are appropriate.
REFERENCE: Health and Safety Code Section 1250
104 County/Jurisdiction of Death
WARNING: Please be certain the COUNTY/JURISDICTION of death is correct BEFORE
registration. COUNTY/JURISDICTION of death cannot be amended. If the
COUNTY/JURISDICTION is not correct, the original death certificate will need to be
administratively sealed and a replacement death certificate with the correct
county/jurisdiction will be required.
Field 104 is auto-populated with information entered during certificate creation. Ensure the
entry reflects the proper jurisdiction where the event occurred. If incorrect, use the Edit
Decedent Information menu option.
The entry must reflect the name of the county/jurisdiction where:
• the death occurred
• the body was found
• the body was brought (the first port of call if death occurred at sea or en route via
airplane)
Long Beach, Pasadena, & Berkeley
Special care must be taken when the event occurs in the cities of Long Beach and Pasadena in
Los Angeles County OR Berkeley in Alameda County. These cities are local health jurisdictions.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 59
What to do . . .
If the death occurred in the city of … Then in Field Select …
unincorporated Pasadena (not within city limits) 104 Los Angeles
incorporated Pasadena (within city limits) 104 Los Angeles - Pasadena
Long Beach 104 Los Angeles - Long Beach
Berkeley 104 Alameda - Berkeley
DEATHS OCCURRING IN TRANSIT
What to do...
If the death
occurred …
Then in
Field
Enter …
in an airplane 101 airplane.
104 the county/jurisdiction having jurisdiction over the city where
the airport of destination is located.
105 en route to (destination). Specify latitude (Lat.) and Longitude
(Long.) coordinates.
106 the city where the airport of destination is located.
on a ship at sea 101 ship.
104 the county/jurisdiction having jurisdiction over the city where
the port of call (City) is located.
105 en route to (destination). Specify latitude (Lat.) and Longitude
(Long.) coordinates.
106 Port of Call (City).
in a bus, car, train,
or ambulance 101 bus, car, train, or ambulance, as appropriate.
104 the county/jurisdiction where the death occurred or the first
stop.
105
indicate the nearest cross streets or position on highway (e.g. x
miles east on US 40). Latitude (Lat.) and Longitude (Long.)
coordinates acceptable.
106 the city.
in an
unincorporated
and/or rural area
101 describe the place of death.
104 the county/jurisdiction where the death occurred.
105 a geographic description. Latitude (Lat.) and Longitude (Long.)
coordinates acceptable.
106 the name of the closest city or town within the district of death,
preceded by "Rural" (e.g., Rural "Metro Town").
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rev July 2021 --- California Death Registration 60
105 Facility Address or Location Where Found
If a hospital, hospice or nursing home/LTC facility was selected from the dropdown in Field
102/103 and the facility was selected in Field 101, Field 105 will auto-populate with the
appropriate information.
If decedent residence or other was selected, enter the full street or rural address or a
descriptive location where the event occurred or the body was found. A physical address or
description or latitude and longitude coordinates are acceptable when the location has no
defined address.
Acceptable entries
• Willow Pass Road, approximately 3/4 mile west of Elk Grove
• Airline en route to Los Angeles
• Latitude 33.1376, Longitude -107.5781
Unacceptable entries
• General delivery
• PO Box numbers
There are four subfields within Field 105.
• Street Number
• Street Name
• Apt/Suite/Unit
• Zip Code
Street Number (optional)
Enter the street number into the subfield only if the location where the event occurred or the
body was found included a street number. Street number must be alphanumeric. A dash (-),
period (.), slash (/), or apostrophe (') are acceptable punctuation.
• 123
• 123B
Street Name (required)
Enter the street name for where the event occurred or the body was found. If the place of
death is a rural route address, or the address is being provided as latitude and longitude
coordinates, use the street name subfield only. Street name must be alphanumeric. A dash (-),
comma (,), period (.), hash (#), slash (/), or apostrophe (') are acceptable punctuation.
• South side of Evewaugh Lane
• RR 2 Box 18
• Lat. 38.66204 Long. 121.510265
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rev July 2021 --- California Death Registration 61
Apt/Suite/Unit (optional)
When applicable, enter the Apt/Suite/Unit number for the location address. Only alphanumeric
entries are acceptable in this subfield. A dash (-), period (.), slash (/), apostrophe ('), hash (#),
comma (,), and parentheses (()) are acceptable punctuation.
• Apt 4B
• Ste 100
Zip Code
Enter the zip code associated with the location address.
A US zip code entry must be a minimum of five digits, but a 5 digit zip code plus 4 digit
extension is acceptable.
DEATHS OCCURRING IN TRANSIT
What to do...
If the death
occurred …
Then in
Field
Enter …
in an airplane 101 airplane.
104 the county/jurisdiction having jurisdiction over the city where
the airport of destination is located.
105 en route to (destination). Specify latitude (Lat.) and Longitude
(Long.) coordinates.
106 the city where the airport of destination is located.
on a ship at sea 101 ship.
104 the county/jurisdiction having jurisdiction over the city where
the port of call (City) is located.
105 en route to (destination). Specify latitude (Lat.) and Longitude
(Long.) coordinates.
106 Port of Call (City).
in a bus, car, train,
or ambulance 101 bus, car, train, or ambulance, as appropriate.
104 the county/jurisdiction where the death occurred or the first
stop.
105
indicate the nearest cross streets or position on highway (e.g. x
miles east on US 40). Latitude (Lat.) and Longitude (Long.)
coordinates acceptable.
106 the city.
in an unincorporated
and/or rural area 101 describe the place of death.
104 the county/jurisdiction where the death occurred.
105 a geographic description. Latitude (Lat.) and Longitude (Long.)
coordinates acceptable.
106 the name of the closest city or town within the district of death,
preceded by "Rural" (e.g., Rural "Metro Town").
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 62
106 City
The city of death must be located within the county of death entered into field 104.
Enter the name of the city where:
• the death occurred
• the body was found
• the body was brought (the first port of call if death occurred at sea or en route via
airplane)
Long Beach, Pasadena, & Berkeley
Special care must be taken when the event occurs in the cities of Long Beach and Pasadena in
Los Angeles County OR Berkeley in Alameda County. These cities are local health jurisdictions.
What to do . . .
If the death occurred in the city of … Then in Field Select …
unincorporated Pasadena (not within city limits) 104 Los Angeles.
incorporated Pasadena (within city limits) 104 Los Angeles - Pasadena.
Long Beach 104 Los Angeles - Long Beach.
Berkeley 104 Alameda - Berkeley.
The death of a person at sea whose body is immediately buried at sea is not reported to the
local registrar having jurisdiction over the first port of call. The death and burial should be
reported to the embassy or nearest consulate having jurisdiction over the vessel or foreign
waters. The U.S. Coast Guard may be contacted for vessels of U.S. registry.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 63
What to do...
If the death
occurred …
Then in
Field
Enter …
in an airplane 101 airplane.
104 the county/jurisdiction having jurisdiction over the city where
the airport of destination is located.
105 en route to (destination). Specify latitude (Lat.) and Longitude
(Long.) coordinates.
106 the city where the airport of destination is located.
on a ship at sea 101 ship.
104 the county/jurisdiction having jurisdiction over the city where
the port of call (City) is located.
105 en route to (destination). Specify latitude (Lat.) and Longitude
(Long.) coordinates.
106 Port of Call (City).
in a bus, car, train,
or ambulance
101 bus, car, train, or ambulance, as appropriate.
104 the county/jurisdiction where the death occurred or the first
stop.
105 indicate the nearest cross streets or position on highway (e.g. x
miles east on US 40). Latitude (Lat.) and Longitude (Long.)
coordinates acceptable.
106 the city.
in an
unincorporated
and/or rural area
101 describe the place of death.
104 the county/jurisdiction where the death occurred.
105 a geographic description. Latitude (Lat.) and Longitude (Long.)
coordinates acceptable.
106 the name of the closest city or town within the district of death,
preceded by "Rural" (e.g., Rural "Metro Town").
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 64
Cause of Death (Fields 107-113)
Cause of Death Overview
Refer to Appendix E — Cause of Death Guidelines in the Help References menu for additional
guidance.
The Cause of Death (COD) section is prepared by the medical certifier and is used to certify the
initiating, immediate and contributing cause(s) of death.
The California death certificate provides four fields (Fields 107A through 107D) for certifiers to
provide information on the decedent’s cause(s) of death.
If transcribing this information from a worksheet, for clarification of acceptable causes of death,
contact your local health department. Avoid using abbreviations or acronyms and check
spelling for unfamiliar terms. A dash (-), period (.), apostrophe (') is acceptable punctuation. The
maximum is 120 characters for each line.
REFERENCE: Health and Safety Code Sections 102825, 102795
107A Immediate Cause
Enter the immediate cause of death in Field 107A. Only one condition may be listed on this line.
107B Due to
List any diseases, injuries, or complication(s) that may have led to the immediate or direct
cause of death as entered in Field 107A. When the certifier includes five or more CODs, more
than one cause may be entered on this line, but all causes listed should fit within the
approximate time frame listed in 107BT, or the time frame listed in 107BT should be the time
frame for the cause of the longest duration listed in that line.
NOTE:
• Conditions listed in 107B, 107C and 107D must have been present before the cause
listed in Field 107A with respect to both time and pathological relationship.
• If there are no other conditions, leave 107B, 107C, or 107D blank.
107C Due to
List any diseases, injuries, or complication(s) that may have led to the conditions reported in
Fields 107A and 107B. When the certifier includes five or more CODs, more than one cause may
be entered on this line, but all causes listed should fit within the approximate time frame listed
in 107CT, or the time frame listed in 107CT should be the time frame for the cause of the
longest duration listed in that line.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 65
107D Due to
List any disease, injury, or complication(s) that may have led to the conditions reported in Fields
107A, 107B, and 107C. The time frame listed in 107DT should be the time frame for the cause
of the longest duration listed in that line. This field may contain only one underlying cause of
death or may be left blank.
107AT-107DT Time Intervals Between Onset and Death
The time intervals between causes for Items 107AT, 107BT, 107CT, and 107DT must be listed in
chronological order and must be supported by etiological sequence. Do not leave these items
blank. Time intervals must be alphanumeric. A dash (-) or period (.) is acceptable punctuation.
Examples:
• MINS
• 1 DAY
• 1 YR
• 10 YRS
The table below provides additional information for completing the time interval. Abbreviations
are acceptable.
What to do...
If … Then …
the onset of death is
unclear or unknown enter UNK.
a specific opinion is not
possible
entries such as IMMED (immediate), INST (instant), SECS
(seconds), HRS (hours), WKS (weeks), MTHS (months), YRS
(years), etc., may be entered. Use abbreviations to fit in the
space available.
Acceptable abbreviations:
• IMMED (immediate)
• INST (instant)
• SEC (second)
• SECS (seconds)
• MIN (minute)
• MINS (minutes)
• HR (hour)
• HRS (hours)
• DAY (day)
• DYS (days)
• WK (week)
• WKS (weeks)
• MO (month)
• MOS (months)
• YR (year)
• YRS (years)
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 66
108 Death Reported to Coroner?
California law requires certain deaths to be reported to the ME/coroner. Funeral homes and
directors are among those responsible for referring cases to the ME/Coroner.
Once the record has been referred to the medical examiner (ME)/coroner, it cannot be
reverted to NO (not referred).
By default, the value in Field 108 is NO. If the death is not referred to the coroner, no further
action is required.
To refer the death certificate to the ME/coroner, select the REFER TO ME/CORONER option
from the CERTIFICATES dropdown. Upon completion of the referral process, the NO (not
referred) will update to YES on the certificate.
Refer to ME/Coroner is now subject to validations. Either the certifier must have attested and
all fields 114-118 are complete or all fields 114-118 are blank, to be completed after referral.
Referral Number
A referral number is not mandatory. Do not enter a referral number unless the ME/coroner has
taken action on the certificate. Coroner Referral Number must be alphanumeric. A dash (-) is
acceptable punctuation.
If the ME/coroner:
• provides a referral number but has not entered it into the system, enter the number in
this field.
• declines the case, the system will enter a NONE in this field.
• does not provide a referral number, enter NONE in this field.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 67
What to do . . .
If … Then …
the attending physician is unable to
state the underlying cause of death the ME/coroner must certify.
the death is due to an external cause the ME/coroner must certify.
an attending physician is not available the ME/coroner must certify.
the physician has attended the
decedent, but not within the last 20
days
the ME/coroner may certify or may authorize the
physician to certify. The ME/coroner may also
certify in addition to the physician certification.
no physician has attended the
decedent within the last 20 days
the ME/coroner may certify or may authorize the
physician to certify. The ME/coroner may also
certify in addition to the physician certification.
the death was due to natural causes
and the decedent was attended by a
physician within the last 20 days
the ME/Coroner is not required to certify. The
attending physician must certify or may designate
another physician to certify, providing the designee
acts in consultation with the attending physician,
and has access to the decedent’s medical records.
The decedent was seen by a licensed
physician assistant under the
supervision of the physician last in
attendance within the last 72 hours
and was a patient in a skilled nursing
center or intermediate care facility
the ME/Coroner is not required to certify. The
licensed physician assistant may certify and should
provide a copy of the death certificate to the
ME/Coroner.
Medical Examiner/Coroner Referral Reasons
After selecting the REFER TO ME/CORONER option from the CERTIFICATES dropdown, the
ME/Coroner's office having jurisdiction based on county of death in Field 104 will be selected
by default. Select a reason from the list. Start typing the first few characters of the desired
reason and select from refined list of results based on the typed information. Selecting the
reason will auto-populate the referral reason field. Optionally, you may enter free text. Then
click the 'continue' button.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 68
Reportable Deaths (Coroner's Cases)
Health and Safety Code Section 102850
A physician and surgeon, physician assistant, funeral director, or other person shall immediately
notify the coroner when he or she has knowledge of a death that occurred or has charge of a
body in which death occurred under any of the following circumstances:
• Without medical attendance.
• During the continued absence of the attending physician and surgeon.
• Where the attending physician and surgeon or the physician assistant is unable to state
the cause of death.
• Where suicide is suspected.
• Following an injury or an accident.
• Under circumstances as to afford a reasonable ground to suspect that the death was
caused by the criminal act of another.
Section GC-27491. (Relevant Sections)
It shall be the duty of the coroner to inquire into and determine the circumstances, manner,
and cause of all:
• violent, sudden, or unusual deaths
• unattended deaths
• deaths wherein the deceased has not been attended by a physician in the 20 days
before death
In addition, deaths related to or following:
• known or suspected self-induced or criminal abortion;
• known or suspected homicide, suicide, or accidental poisoning;
• deaths known or suspected as resulting in whole or in part from or related to accident
or injury either old or recent;
• deaths due to drowning, fire, hanging, gunshot, stabbing, cutting, exposure, starvation,
acute alcoholism, drug addiction, strangulation, aspiration, or where the suspected
cause of death is sudden infant death syndrome;
• death in whole or in part occasioned by criminal means;
• deaths associated with a known or alleged rape or crime against nature;
• deaths in prison or while under sentence;
• deaths known or suspected as due to contagious disease and constituting a public
hazard;
• deaths from occupational diseases or occupational hazards;
• deaths of patients in state mental hospitals serving the mentally disabled and operated
by the State Department of Mental Health;
• deaths of patients in state hospitals serving the developmentally disabled and operated
by the State Department of Developmental Services;
• deaths under such circumstances as to afford a reasonable ground to suspect that the
death was caused by the criminal act of another; and
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 69
• any deaths reported by physicians or other persons having knowledge of death for
inquiry by coroner.
Any funeral director, physician, or other person who has charge of a deceased person's body,
when death occurred as a result of any of the causes or circumstances described in this section,
shall immediately notify the coroner. Any person who does not notify the coroner as required
by this section is guilty of a misdemeanor.
For purposes of inquiry, the body of one who is known to be dead from any of the causes or
under any of the circumstances described in Section 27491 shall not be disturbed or moved
from the position or place of death without permission of the coroner or the coroner's
appointed deputy. Any violation of this subdivision is a misdemeanor.
REFERENCE: Health and Safety Code Section 102850, Government Code Section 27491.2(b)
109 Biopsy Performed?
Was a biopsy performed for any of the conditions listed in Field 107?
Do not leave this field blank. Select YES or NO from the dropdown.
A biopsy refers to an examination of tissues removed from a living body to discover the
presence, cause, or extent of a disease. This is to track ante-mortem tissue testing, not post-
mortem tissue examination.
110 Autopsy Performed?
Do not leave this field blank. Select YES or NO from the dropdown. If YES is selected, you will
be required to answer Field 111.
111 Used in Determining Cause?
If Field 110 is NO, no further action is required for Field 111. The system will not display Field
111.
If Field 110 is YES, Field 111 is displayed. Select YES or NO from the dropdown in Field 111,
indicating whether or not a physician or medical examiner/coroner's office used an autopsy to
make a determination as to the cause of death.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 70
112 Other Significant Conditions Contributing to Death but Not Resulting in the
Underlying Cause Given in 107
Do not leave blank. If no other conditions are known, then enter NONE. Ensure the most
important conditions contributing to the death are listed first.
Enter all other significant conditions (e.g., important diseases, initiating events, etc.) that were
present at the time of death, but did not lead to the underlying cause(s) listed in Field 107.
Other Significant Conditions must be alphanumeric. A dash (-), period (.), apostrophe ('), comma
(,), or semicolon (;) is acceptable punctuation. If the case is pending a medical
examiner/coroner’s review, a single dash (-) is acceptable.
The initiating conditions present at the time of death may be completely unrelated to the other
significant conditions, arising independently of each other, or they may be causally related to
each other (e.g., one condition may lead to another which in turn leads to a third condition).
Significant conditions may include:
• the existence of any cancer
• any disease, abnormality, or injury believed to have adversely affected the decedent
• use of alcohol and/or other substances
• a recent pregnancy believed to have contributed to death
• a history of tobacco use that may have contributed to death
REFERENCE: Health and Safety Code Section 102825
113 Was Operation Performed for Any Condition in Fields 107 or 112? (If yes, list type of
operation and date)
Select YES, NO or UNKNOWN from the dropdown.
• If YES is selected, enter the type of operation(s) performed and the date(s) performed in
the allotted space. Ensure the most important operations preceding the death are listed
first. Include the date(s) performed in MM/DD/YYYY format. Operations Performed
must be alphanumeric. A dash (-), period (.), apostrophe ('), comma (,), slash (/), or
semicolon (;) is acceptable punctuation.
• If NO is selected, the system will auto-populate NO in Field 113.
• If UNKNOWN is selected, the system will auto-populate UNK in Field 113.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 71
What to do . . .
If … Then enter …
the exact date is unknown for any operation
that occurred more than one year prior to the
date of death
the estimated month and year only with
dashes for the unknown day separated by
forward slashes (e.g., 07/--/1998).
the month and day are unknown
enter the year with dashes for the
unknown month and day separated by
forward slashes (e.g., --/--/1998).
no estimate can be made UNK.
113A If Female, Pregnant in Last Year?
This field is required if the decedent is between 5 years and 75 years of age, regardless of sex
selected in Field 6.
This field will not appear if the decedent is:
• less than 5 years of age
• greater than 75 years of age
If the decedent is between 5 and 75 years of age, select YES, NO or UNKNOWN from the
dropdown as appropriate to indicate if the decedent was pregnant within the year prior to
death.
If YES is selected from the dropdown, an additional dropdown will require you to select from
the following list:
• Pregnant at time of death
• Not pregnant at time of death but pregnant within 42 days of death
• Not pregnant at time of death but pregnant within 43 days to one year of death
If YES is selected from the dropdown, and the decedent is less than 10 years or greater than 54
years of age, EDRS will ask you to review and verify the decedent’s data before registration.
If YES is selected from the dropdown, and the decedent's sex is not Female, EDRS will ask you to
review and verify the decedent’s data before registration.
The information may be obtained by the following:
• observation
• autopsy
• review of the medical record
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 72
A pregnancy test, autopsy, and/or review of the medical records are not required to complete
the death certificate.
REFERENCE: Health and Safety Code Section 102875
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 73
Physician’s Certification (Fields 114-118)
114A and 114B Dates of Attendance
The physician or the physician's designee must supply the date the decedent was first treated
by the physician and the date the decedent was last seen alive by the physician. The dates must
be entered in MM/DD/YYYY format.
What to do . . .
If … Then …
he decedent was last seen by the
physician's licensed physician's assistant
enter the dates the licensed physician's assistant
attended, not the dates the physician attended.
the decedent was last seen by a
registered nurse, who is a member of a
hospice care interdisciplinary team as
defined by H&SC Sec. 1746
enter the dates the hospice team registered nurse
attended, not the dates the physician attended.
the date of attendance is more than one
year prior to the date of death and the
exact date is unknown
enter the year with dashes for the unknown
month and day separated by forward slashes
(e.g., 07/--/1976, or --/--/1976). UNK is acceptable
if the date is unknown.
the date of death is amended the date last seen alive may need to be amended.
115 & 116 Signature and Title of Certifier & License Number
The signature, title and license number along with the fax phone number of the Medical
Certifier are entered in the Request Remote Attestation screen.
To enter the Certifier's name and license, select the REQUEST REMOTE ATTESTATION option
from the CERTIFICATES dropdown. Use the magnifying glass icon adjacent to the License
Number field to access the Attending Physician Browser. Search for the certifier by first name,
last name or license number. Start typing the first few characters of the license number, first
name, and/or last name and select from refined list of results based on the typed information.
Selecting the certifier will auto-populate the certifier's name and license number.
If the certifier cannot be located within the Attending Physician Browser, manually enter the
certifier’s name into the appropriate fields.
• First
• Middle
• Last Name
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 74
Certifier Name
The certifier’s name and degree must be present in Field 115 of the death certificate. Names
must be alphabetic. A dash (-), period (.), or apostrophe (') is acceptable punctuation. If the
certifier does not have a first or middle name, enter a dash (-). The dash will not print on the
certificate.
Suffix
Select the appropriate suffix for the certifier from the dropdown. If the certifier does not have a
suffix, this field may be left as a double dash (--).
Degree/Title
Select the appropriate degree for the certifier from the dropdown.
License Number
Fields 114 - 118 may only be left blank if a medical examiner/coroner is attesting to the medical
information on the certificate. The license number in Field 116 must be that of the person
attesting to the medical information on the certificate.
If the certifier, including provisionally licensed physicians, does not have a California license,
enter the state abbreviation followed by the license number (example NV12345). California
License Numbers must be alphanumeric. Do not include spaces, dash (-), or other punctuation.
REFERENCE: Health and Safety Code Section 102800, 102795, 102825; ACL 08-23, ACL 12-02,
ACL 13-19, ACL 15-22
Signatures
Retired physicians, chiropractors, midwives, and certified nurses are not authorized to certify to
the facts of death.
The certifier shall provide a signature or electronic attestation for Field 115. Signatures should
be contained within the field area provided. The signature, title and date must be legible and
unambiguous. If signatures overlap into additional fields, they must not create ambiguity in that
field. Unclear letters or numbers are cause for rejecting the attestation and the certificate.
Licensed Physician’s Assistant (PA) may only sign in item 115 if all the following are true:
• PA last attended within 72 hours of date of death
• PA was under the supervision of a licensed M.D. or D.O. (as indicated in item 118), and
• Decedent was in a skilled nursing or intermediate care facility.
Per All County Letter (ACL) 15-22, death certificates submitted to the Local and State Registrar
should not be rejected solely because a medical certifier neglects to include his or her title (e.g.,
MD, DO, or PA) when attesting to the certificate. The attestation shall be considered acceptable
if the appropriate certifier has attested with his or her full name or customary signature
equivalent, by ink or remote attestation.
Inclusion of the certifier’s title is encouraged, as it assists state and local efforts to verify that
the appropriate certifier attested. If absence of the certifier’s title causes ambiguity, local
registrars are encouraged to verify the attestation with the medical certifier.
REFERENCE: Health and Safety Code Section 102795 and ACL 15-22
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 75
Fax Attestation
Review the fax attestation by selecting the Review RA Media option from the Certificate
Options dropdown. The fax image must conform to the following:
• The signature of medical certifier must be included in Field 115.
• The certifier’s signature must be an original ink signature. It cannot be stamped or be a
reproduced image of a signature.
• No alterations or additions are allowed on the page.
• All Medical Information must be legible.
• The signature and date (if provided) must be unambiguous.
• It is not necessary for certifiers to provide a date (EDRS automatically captures the date
the certifier faxes the document into the system).
• When a date is provided, it cannot be prior to the date of death, nor after the date of
local registration.
The fax attestation may not be used to make changes to the information shown on the death
certificate. If the certifier desires changes, the changes must be incorporated into the death
certificate before requesting an additional attestation.
A flawed fax attestation will result in certificate rejection.
REFERENCE: ACL 15-22
Voice Attestation
Review the voice attestation by selecting the Review RA Media option from the Certificate
Options dropdown.
The voice attestation phrase must contain the following:
• Medical certifier’s own name, spoken in certifier’s own voice.
• First and last name of the decedent, as present on the certificate.
• Medical certifier must designate they are attesting to the accuracy of the cause of death
information as provided on the certificate.
The license number phrase must state the following:
• Medical certifier’s entire license number
The voice attestation may not be used to make changes to the information shown on the death
certificate. If the certifier desires changes, the changes must be incorporated into the death
certificate before requesting an additional attestation.
A flawed voice attestation will result in certificate rejection.
REFERENCE: ACL 13-19
117 Date Certifier Signed
Field 117 is the date the physician certified the accuracy of the information on the certificate.
EDRS will auto-populate the date in Field 117 when the system accepts the certifier's
attestation. Fields 114-118 may only be left blank if a medical examiner/coroner is attesting to
the certificate.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 76
118 Attending Physician’s Name and Mailing Address
Utilize the magnifying glass icon for Field 118 to access the Attending Physician Browser. Search
for the attending physician by first name, last name, or license number. Select the attending
physician to auto-populate all subfields of Field 118.
If the attending physician cannot be located or is different than what is found within the
browser, manually enter the attending physician’s name and address into the appropriate
subfields.
There are eleven subfields for Field 118, as follows:
• First Name
• Middle Name
• Last Name
• Suffix
• Degree/Title
• Mailing Address Type
• Street Number
• Street Name
• Apt/Suite/Unit
• City
• Zip Code
Attending Physician Name
Names must be alphabetic. A dash (-), period (.), or apostrophe (') are acceptable punctuation.
If the attending does not have a first or middle name, enter a dash (-). The dash will not print
on the certificate.
• First
• Middle
• Last Name
Suffix
Select the appropriate suffix for the attending from the dropdown. If the attending does not
have a suffix, this field may be left as a double dash (--).
Degree/Title
Select the appropriate degree for the attending from the dropdown.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 77
Attending Address
There are six subfields for attending's address within Field 118:
• Mailing Address Type
• Street Number
• Street Name
• Apt/Suite/Unit
• City
• Zip Code
This address may be a post office box number. The information is used to contact the attending
to request missing and/or additional information.
Mailing Address Type
Select the appropriate address type from the dropdown in Field 118. The available options are:
• US State
• US Territory
• Canadian Province
• Mexican State
• Other Country
• Other Country UNK
• Unknown
After an address type has been designated, a subsequent field will populate, requesting further
details regarding the state/foreign country.
Select the appropriate state, generally CALIFORNIA, from the dropdown.
Street Number (optional)
Enter the street number into the subfield for street number if the attending’s mailing address
included a street number. Street number must be alphanumeric. A dash (-), period (.), slash (/),
or apostrophe (') are acceptable punctuation.
• 123
• 123B
Street Name (required)
Enter the street name of the attending’s street mailing address. If the attending’s mailing
address is a rural route address, or the address is being provided as latitude and longitude
coordinates, use the street name subfield only. A dash (-), comma (,), period (.), hash (#), slash
(/), or apostrophe (') are acceptable punctuation.
• South side of Evewaugh Lane
• RR 2 Box 18
• Lat. 38.66204 Long. 121.510265
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 78
Apt/Suite/Unit (optional)
This subfield may be left blank. When applicable, enter the Apt/Suite/Unit number.
Apt/Suite/Unit must be alphanumeric. A dash (-), period (.), slash (/), apostrophe ('), hash (#),
comma (,), and parentheses (()) are acceptable punctuation.
• Apt 4B
• Ste 100
City
Enter the name of the city associated with the attending’s mailing address. City must be
alphanumeric. A dash (-), period (.), or apostrophe (') is acceptable punctuation.
Zip Code
Enter the attending’s zip code or postal code associated with the attending’s mailing address.
A US zip code entry must be a minimum of five digits, but a 5-digit zip code plus 4 digit
extension.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 79
Coroner’s Use Only (Fields 119-128)
Only Medical Examiner/Coroners or ME/Coroner staff may enter injury information in Fields
119-125.
119 Manner of Death (Coroner’s Use Only)
If the medical examiner/coroner has accepted the case, they are required to select a manner of
death and certify the death certificate.
Only the medical examiner/coroner or ME/Coroner staff may enter information in this field.
Select the entry that most clearly describes the manner in which death occurred. The
dropdown options are as follows:
• NATURAL
• SUICIDE
• HOMICIDE
• ACCIDENT
• PENDING INVESTIGATION
• COULD NOT BE DETERMINED
NATURAL
Ordinarily, injury information should not be entered when the manner of death is NATURAL.
However, at the coroner's discretion, a relevant entry may be made if circumstances compel.
SUICIDE, HOMICIDE, ACCIDENT
If the manner of death is SUICIDE, HOMICIDE, ACCIDENT, Fields 120 - 125 (injury information)
must be completed and the medical examiner/coroner must certify the entries.
PENDING INVESTIGATION, COULD NOT BE DETERMINED
If the manner of death is PENDING INVESTIGATION or COULD NOT BE DETERMINED, Fields 120
- 125 should be completed if the information is available, at the discretion of the medical
examiner/coroner's office. If entries are present in Fields 120 – 125, the medical
examiner/coroner must certify the entries.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 80
120 Injured at Work?
Fields 120-125 are the responsibility of the medical examiner/coroner.
Only the medical examiner/coroner or ME/Coroner staff may enter information in this field.
If any entry is made in any Field from 120 - 125, none of the other fields in this sequence (120 -
125) may be left blank. If entries are present in Fields 120 – 125, the medical examiner/coroner
must certify the entries.
Select YES or NO or UNKNOWN from the dropdown when appropriate.
121 Injury Date
Fields 120-125 are the responsibility of the medical examiner/coroner.
Only the medical examiner/coroner or ME/Coroner staff may enter information in this field.
If any entry is made in any Field from 120 - 125, none of the other fields in this sequence (120 -
125) may be left blank. If entries are present in Fields 120 – 125, the medical examiner/coroner
must certify the entries.
Select the appropriate date from the calendar icon, or enter the date of injury entered in Field
121.
The injury date and date of death may not necessarily be the same. The injury date may be
earlier, or may be the same date as the death, but cannot be later than the date of death.
If ACCIDENT, SUICIDE, or HOMICIDE is selected in Field 119, the actual or estimated date of
injury must be entered in Field 121.
If UNK was entered in Field 121, enter UNK in field 122.
What to do . . .
If … Then …
the exact date of the injury is
unknown
enter the estimated date and select EST from the
dropdown.
the day is unknown
enter the estimated month and year with dashes for the
unknown day separated by forward slashes (e.g., 07/--
/1998).
the month and day are unknown enter the year with dashes for the unknown month and
day separated by forward slashes (/) (e.g., --/--/2010).
no estimate can be made enter UNK.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 81
122 Hour
Fields 120-125 are the responsibility of the medical examiner/coroner.
Only the medical examiner/coroner or ME/Coroner staff may enter information in this field.
If any entry is made in any Field from 120 - 125, none of the other fields in this sequence (120 -
125) may be left blank. If entries are present in Fields 120 – 125, the medical examiner/coroner
must certify the entries.
Enter the actual or estimated time that the injury occurred, using the 24-hour clock. If estimate
is used select EST from dropdown. If no estimate is possible, enter UNK for unknown.
If UNK was entered in Field 121, enter UNK in Field 122.
24-hour clock Please refer to the time conversion table below.
TIME CONVERSION TO 24-HOUR CLOCK
Regular Clock 24-Hour Clock Regular Clock 24-Hour Clock
12:00 a.m. 0000 12:00 noon 1200
1:00 a.m. 0100 1:00 p.m. 1300
2:00 a.m. 0200 2:00 p.m. 1400
3:00 a.m. 0300 3:00 p.m. 1500
4:00 a.m. 0400 4:00 p.m. 1600
5:00 a.m. 0500 5:00 p.m. 1700
6:00 a.m. 0600 6:00 p.m. 1800
7:00 a.m. 0700 7:00 p.m. 1900
8:00 a.m. 0800 8:00 p.m. 2000
9:00 a.m. 0900 9:00 p.m. 2100
10:00a.m. 1000 10:00 p.m. 2200
11:00a.m. 1100 11:00 p.m. 2300
11:59 p.m. 2359
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 82
123 Place of Injury
Fields 120-125 are the responsibility of the medical examiner/coroner.
Only the medical examiner/coroner or ME/Coroner staff may enter information in this field.
If any entry is made in any Field from 120 - 125, none of the other fields in this sequence (120 -
125) may be left blank. If entries are present in Fields 120 - 125, the medical examiner/coroner
must certify the entries.
Select a general category for the type of place where the injury occurred. The available
categories are as follows:
• FARM
• HOME
• INDUSTRIAL AND/OR CONSTRUCTION AREA
• NO INJURY
• OTHER SPECIFIED PLACES
• RESIDENTIAL INSTITUTION
• SCHOOL, OTHER INSTITUTIONAL OR PUBLIC ADMINISTRATIVE AREA
• SPORTS AND/OR ATHLETICS AREA
• STREET AND/OR HIGHWAY
• TRADE AND/OR SERVICE AREA
• UNSPECIFIED PLACE
If an appropriate category is not available from this list, select OTHER SPECIFIED PLACES or
UNSPECIFIED PLACE and enter an appropriate description in the field adjacent to the
dropdown. Place of injury must be alphanumeric. A dash (-), period (.), apostrophe ('),
ampersand (&), parentheses () is acceptable punctuation. Do not enter the name of a firm or
organization.
124 Describe How Injury Occurred
Fields 120-125 are the responsibility of the medical examiner/coroner.
Only the medical examiner/coroner or ME/Coroner staff may enter information in this field.
If any entry is made in any Field from 120 - 125, none of the other fields in this sequence (120 -
125) may be left blank. If entries are present in Fields 120 – 125, the medical examiner/coroner
must certify the entries.
Briefly describe how the injury occurred, indicating the circumstances of the accident or injury.
The description must be alphanumeric. A dash (-), period (.), comma (,), colon (:), semicolon (;),
apostrophe ('), ampersand (&), parentheses (), or forward slash (/) is acceptable punctuation.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 83
Gunshot deaths must be identified as rifle, shotgun, handgun, or as caused by a military
connection involving a military weapon.
Motorcycle and automobile-related deaths must state whether the decedent was the driver,
passenger, etc. Include available information regarding seatbelt use in automobiles.
The following are examples of brief descriptions:
• Decedent unrestrained driver in an auto-truck collision. Decedent crossed line and hit
oncoming vehicle head on.
• Unrestrained passenger ejected from truck.
• Helmeted motorcyclist involved in a collision with another vehicle
• Inhaled carbon monoxide from auto exhaust through hose in an enclosed garage.
• Self-inflicted hanging by rope from rafters in decedent's home.
• Self-inflicted hanging by electrical cord in decedent's garage.
• Self-inflicted gunshot wound to the head with AR-15 Rifle.
• Self-inflicted gunshot wound to the chest with 9MM pistol.
• Self-inflicted incised wounds to the neck and wrist.
• Shot by another with .45 caliber revolver.
• Blunt force injuries with wrench by unknown assailant.
• Jumped off Benicia - Martinez Bridge.
• Decedent had a ground level fall while walking in own residence.
• Over ingested alcoholic beverages. Decedent's blood alcohol level was 0.450 grams
percent.
• Overdose of injected methamphetamine and ingested opiates.
• Drowned in residential pool while under the influence of multiple illicit drugs.
125 Location of Injury
Fields 120-125 are the responsibility of the medical examiner/coroner.
Only the medical examiner/coroner or ME/Coroner staff may enter information in this field.
If any entry is made in any Field from 120 - 125, none of the other fields in this sequence (120 -
125) may be left blank. If entries are present in Fields 120 – 125, the medical examiner/coroner
must certify the entries.
Enter the complete address or other geographical description of the place where the injury
occurred. Latitude and longitude coordinates are acceptable.
There are ten subfields for the location of injury:
• Location of Injury Description
• Address Type
• State
• Street Number
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 84
• Street Name
• Apt/Suite/Unit
• City
• State
• Zip Code
• Postal Code
You may enter both a location/description and an address. At minimum, location/description or
a complete address is required. A complete address includes street name, city, state, and zip
code.
Location of Injury Description
Enter a location of injury description. Latitude and longitude coordinates may be used.
Location/Description must be alphanumeric. A dash (-), period (.), comma (,), colon (:),
semicolon (;), apostrophe ('), forward slash (/) are acceptable punctuation.
Address Type
Select the appropriate address type for the location of injury from the dropdown in Field 125.
The available options are:
• US State
• US Territory
• Canadian Province
• Mexican State
• Other Country
• Other Country UNK
• Unknown
After an address type has been designated, a subsequent field will populate, requesting further
details regarding the location of injury.
What to do...
If … Then select…
US State
US State from the dropdown. Then select the appropriate state from
the dropdown. The US state abbreviation will print on the death
certificate.
US Territory
US Territory from the dropdown. Then select the appropriate
territory from the dropdown. The US territory abbreviation will print
on the death certificate.
Canadian Province
Canadian Province from the dropdown. Then select the appropriate
province from the dropdown. The Canadian province abbreviation
and CN will print on the death certificate.
Mexican State
Mexican State from the dropdown. Then select the appropriate state
from the dropdown. The Mexican state abbreviation and MX will print
on the death certificate.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 85
Other Country
Other Country from the dropdown. Then use the reference browser
(click on the magnifying glass icon) to select the foreign country. EDRS
will populate the foreign country or foreign country abbreviation.
unknown US State US State from the dropdown. Then select UNK from the dropdown.
UNK will print on the death certificate.
unknown US
Territory
US Territory from the dropdown. Then select Unknown from the
dropdown. UNK will print on the death certificate.
unknown Canadian
Province
Canadian Province from the dropdown. Then select Unknown from
the dropdown. UNK, CN will print on the death certificate.
Alternatively, you may leave the Canadian Province dropdown
unselected (double dash) and CN will print.
unknown Mexican
State
Mexican State from the dropdown. Then select Unknown from the
dropdown. UNK, MX will print on the death certificate. Alternatively,
you may leave the Mexican state dropdown unselected (double dash)
and MX will print on the death certificate.
unknown Other
Foreign Country
Other Country UNK from the dropdown. No further action is needed.
FRN-UNK will print on the death certificate.
Unknown Unknown from the dropdown. No further action is needed. UNK will
print on the death certificate.
Street Number (optional)
Enter the street number into the subfield for street number if the location of injury included a
street number. Street number must be alphanumeric. A dash (-), period (.), slash (/), or
apostrophe (') are acceptable punctuation.
• 123
• 123B
Street Name (required)
Enter the street name of the location of injury. If the location of injury is a rural route address,
or the address is being provided as latitude and longitude coordinates, use the street name
subfield only. Street name must be alphanumeric. A dash (-), comma (,), period (.), hash (#),
slash (/), or apostrophe (') are acceptable punctuation.
• South side of Evewaugh Lane
• RR 2 Box 18
• Lat. 38.66204 Long. 121.510265
A post office box address is not acceptable.
Apt/Suite/Unit (optional)
This subfield may be left blank. Enter the Apt/Suite/Unit if the location of injury included an
apartment, suite, or unit number. Only alphanumeric entries are acceptable in this subfield. A
dash (-), period (.), slash (/), apostrophe ('), hash (#), comma (,), and parentheses (()) are
acceptable punctuation.
• Apt 4B
• Ste 100
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 86
City
Enter the name of the city associated with the location of injury. City must be alphanumeric. A
dash (-), period (.), or apostrophe (') is acceptable punctuation.
Zip Code
Enter the zip code or postal code associated with the location of injury.
A US zip code entry must be a minimum of five digits, but a 5-digit zip code plus 4 digit
extension.
126 Signature of Coroner/Deputy Coroner
If entries are present in Fields 119 – 125, the medical examiner/coroner must certify the
entries.
EDRS will auto-populate Field 126 with the electronic signature of the coroner/deputy coroner
when the coroner/deputy coroner attests the record. The coroner/deputy coroner’s office
should alert the funeral home when attestation has been completed. If the signature is not
correct, please contact the EDRS help desk.
127 Date
If entries are present in Fields 120 – 125, the medical examiner/coroner must certify the
entries.
EDRS will auto-populate Field 127 with the date the coroner/deputy coroner attests the record.
The date will be inserted in MM/DD/YYYY format.
128 Typed Name, Title of Coroner/Deputy Coroner
If entries are present in Fields 120 – 125, the medical examiner/coroner must certify the
entries.
EDRS will auto-populate Field 128 with the name and title of the coroner/deputy coroner
attesting the record. If the name or title is not correct, please contact the EDRS help desk.
The information will be entered by EDRS utilizing user profile information submitted by the
medical examiner/coroner when he or she was authorized to use the system. The title entered
in Field 128 on the death certificate should reflect the capacity in which the medical
examiner/coroner is acting (i.e., the position held by the individual that provides the authority
to certify the facts of death). The title of the certifier must be medical examiner, coroner, or
deputy coroner. Any other title, such as a law enforcement title (e.g., sheriff, commander),
which does not provide legal authority to certify the facts of death, should not be used unless
the authorizing title is also used.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 87
Court Order Delayed Registration of Death (VS 109)
Description
A Court Order Delayed Registration of Death is the means to register a California death when
the event was not previously registered, or a certified copy is not available. A verified petition is
filed by any beneficially interested person in either the county of residence of the person whose
death is being established (does not have to be in California), or in the California county where
the death was alleged to have occurred.
REFERENCE: Health and Safety Code Sections 103450, 103455 and 103465
More information can be found at https://www.cdph.ca.gov/Programs/CHSI/Pages/Correcting-or-
Amending-Vital-Records.aspx
Filing the VS 109
At the time of the hearing, the superior court must be presented with a completed Order
Establishing Fact of Death/Court Order Delayed Registration of Death (VS 109) form. The VS 109
must be an original form. Photocopies are not acceptable.
After the court establishes the fact of death, the applicant must submit the following items to
the State Registrar:
• Appropriate fee
• Certified copy of the Order Establishing Fact of Death (VS 109)
• Completed Court Order Delayed Registration of Death (VS 109)
NOTE: California Department of Public Health – Vital Records (CDPH-VR) will not return the
court order after the death certificate is prepared. If any of these items are not included, the
request will be returned to the submitter for correction.
REFERENCE: Health and Safety Code Sections 103485
Fees
Fees should be paid by check or money order, payable to CDPH-VR. International money orders
for out-of-country requests should be payable in U.S. dollars.
Certified copy of court order
A certified copy of the court order must be a copy of the order that was originally prepared by
the court. It cannot be an original printout. If the court gives an original printout, ask them to
make a photocopy that includes:
• An original court seal.
• A signature (or signature stamp) of the judge.
• A signature (or signature stamp) of the court clerk.
The certified copy must have an original court seal and a signature (or signature stamp) of the
court clerk. Documents containing photocopies of the court seal are not acceptable. The court
seal, certification stamp with date and signature must appear on the Order Establishing the Fact
of Death (front or back). Seals, certifications, and signatures provided on the Court Order
Delayed Registration of Death or blank sheets of paper are not acceptable. The filed/endorsed
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 88
stamp provided in the top right corner of the court order is not the court clerk’s certification.
The applicant should make and keep a copy of the court order for his/her own record
Certified copy of certificate
Upon State registration, a certified copy of the certificate will be sent to the applicant.
The State Registrar will also provide a local office copy of the court ordered delayed certificate
to the local registrar and the county recorder in which the event occurred. Upon receipt, the
local registrar may issue a disposition permit if necessary.
NOTE: Court ordered delayed death certificates should be indexed and filed with the other
death certificates.
Amending court ordered delayed certificates
In the event that additional information needs to be added or modified on the court order
delayed certificate, the affidavit form VS 24 should be used.
Established guidelines for amending standard death certificates may be used, however, only
those fields listed on the court order delayed certificate may be amended.
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rev July 2021 --- California Death Registration 89
Mass Fatalities
Overview
In the event of a mass fatalities incident, the law authorizes ME/Coroners to file a single verified
petition with the superior court to judicially establish the fact, time, and place of death for
individuals who die in a mass fatalities incident.
If remains are located, standard death certificates should be prepared for those individuals.
REFERENCE: Health and Safety Code Section 103450(c)
Definition
The definition of a mass fatalities incident is a situation where any of the following conditions
exist:
• There are more dead bodies than can be handled using local resources
• Numerous persons are known to have died, but no bodies were recovered from the site
of the incident
• Numerous persons are known to have died, but the recovery and identification of the
bodies of those persons is impracticable or impossible
The county coroner or medical examiner shall make this determination.
REFERENCE: Health and Safety Code Section 103451
Filing of petition with the clerk of the superior court
Upon filing of a petition for the determination of the fact of death in the event of a mass
fatalities incident, the clerk shall set a hearing no later than 15 days from the date the petition
was filed.
The petitioner shall make a reasonable effort to provide notice of the hearing to the known
heirs of the deceased, up to the second degree of relationship. Failure to do so will not
invalidate the judicial proceedings regarding the determination of fact of death.
REFERENCE: Health and Safety Code Section 103466
Initial contact
The medical examiner/coroner or their designee should contact the State Registrar upon the
determination of a mass fatality incident. The State Registrar will request that a list of all known
fatalities be provided to the local and state registrar’s offices. This list should be updated as
additional information becomes available, including the type of certificate, court ordered or
standard, that will be prepared for each decedent.
The State Registrar will work closely with the ME/Coroner and local registrar’s office to ensure
that all certificates are registered in an expedited manner and that only one certificate is
registered for each fatality.
DEATH CERTIFICATE
rev July 2021 --- California Death Registration 90
Obtaining forms
The local registration district and/or ME/Coroner should contact the State Registrar for
verification of the latest version of the Court Order Delayed form and for assistance in obtaining
a supply of the forms.
Standard certificates
The local registrar will be responsible for the registration of standard certificates for those
fatalities where remains are located.
Completed standard certificates that have been registered by the local registrar are to be
batched separately and forwarded to the State Registrar for processing.
Fee
There is a processing fee for court order delayed certificates. The fee will include a certified
copy of the record.
The State Registrar will provide a local office copy of the court order delayed certificate to the
local registrar and the county recorder in which the incident occurred, without delay. Upon
receipt, the local registrar may issue a disposition permit if necessary.
The State Registrar will also provide a certified copy of the registered court order delayed
certificate to the spouse or next of kin of the decedent. If there is no spouse or next of kin, the
copy shall be provided to the coroner, medical examiner, or county recorder of the county of
death.
REFERENCE: Health and Safety Code Section 103490
Amending court order delayed certificates
If additional information needs to be added or modified on the court order delayed certificate
after it is has been registered with the State Registrar’s office, the VS 24 affidavit form should
be used.
Only those fields listed on the court order delayed certificate may be amended. Refer to
established guidelines for amending standard death certificates in the Death Registration
Handbook for specific information regarding amendments.
Remains later located and identified
If remains are later located and identified for an individual where a court order delayed
certificate was prepared, a new standard certificate must not be prepared. Each decedent must
only have one death certificate. Requests to replace a court-ordered certificate with a standard
certificate must be referred to the State Registrar.
The remains should be disposed of following regular state laws and guidelines. The court order
delayed certificate may be amended to reflect the disposition of the remains.