TENNESSEE DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
DECEDENT
DECEDENT’S LEGAL NAME
First Name
Middle Name
Last Name
Suffix
SEX
DATE OF DEATH
/
Month
/
Day
Year
(Month, Day, Year)
TIME OF DEATH
(Approx. )
AGE-Last Birthday (Years)
UNDER 1 YEAR
Months
Days
UNDER 1 DAY
Hours
Minutes
DATE OF BIRTH
-
Month
-
Day
Year
(Month, Day, Year)
BIRTHPLACE (City and State or Foreign Country)
IF DEATH OCCURRED IN A HOSPITAL
Inpatient
ER/Outpatient
DOA
IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL
Hospice facility
Nursing home/Long term care facility
Decedent’s home
Other residence
Other (Specify) _________________
FACILITY NAME (If not institution, give street and number)
CITY OR TOWN
COUNTRY OF DEATH
MARITAL STATUS
Married
Married, but separated
Widowed
Divorced
Never married
Unknown
SURVIVING SPOUSE (If wife, give name prior to first marriage)
DECEDENT’S USUAL OCCUPATION
KIND OF BUSINESS/INDUSTRY
SOCIAL SECURITY NUMBER
RESIDENCE-STATE OR FOREIGN COUNTRY
COUNTRY
CITY OR TOWN
STREET AND NUMBER
INSIDE CITY LIMITS
Yes
No
ZIP CODE
WAS DECEDENT EVER IN US ARMED FORCES?
Yes
No
DECEDENT’S EDUCATION (Check the box that best describes the highest degree or level of school completed at the time of death)
8th grade or less
9th – 12th grade; no diploma
High school graduate or GED completed
Some college credit, but no degree
Associate degree (e.g., AA, AS)
Bachelor’s degree (e.g., BA, AB, BS)
Master’s degree (e.g.,MA,MS,MEng,MEd,MSW,MBA)
Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)
Unknown
DECEDENT OF HISPANIC ORIGIN? (Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check the “No” box if decedent is not Spanish/Hispanic/Latino)
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latino (Specify) ________________
Unknown
DECEDENT’S RACE (Check one or more races to indicate what the decedent considered himself or herself to be)
White
Black or African American
American Indian or Alaska Native (Name of the enrolled or principal tribe) _____________
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (Specify) ____________________
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (Specify) ____________________
Other (Specify) ____________________
Unknown
PARENTS
FATHER’S NAME
First Name
Middle Name
Last Name
MOTHER’S NAME PRIOR TO FIRST MARRIAGE
First Name
Middle Name
Last Name
INFORMANT’S NAME
RELATIONSHIP TO DECEDENT
MAILING ADDRESS
Street Address
Street Address 2
City
State
Zip Code
DISPOSITION
METHOD OF DISPOSITION
Burial
Cremation
Donation
Entombment
Removal from State
Other (Specify) ____________________
PLACE OF DISPOSITION (Name of cemetery, crematory, other place)
LOCATION - City or Town and State
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