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Grief Perspectives
Scholar's Corner
Resource Review
Your Professional Library

Why Death Certificates are Important

by William G. Hoy
Referring to the newly-drafted United States Constitution, colonial statesman Benjamin Franklin (1907) wrote to Jean-Baptiste Leroy: “Our new Constitution is now established, and has an appearance that promises permanency; but in this world nothing can be said to be certain, except death and taxes”  (emphasis added) (p. 79). Everybody dies eventually so, at least in the developed world, everybody eventually has a death certificate with his or her name on it!

The death certificate is a legal document establishing the facts of an individual’s death and definitively identifying the deceased for legal purposes. The death certificate includes three main components: demographic and historical information identifying the deceased person, data certifying the supposed cause and manner of the death, and descriptions of the corpse’s disposition. In addition to legally establishing an individual’s death, the data can be combined with other deaths during a specific time period to discover patterns of disease for the purposes of prevention and treatment.
Most developed nations have elaborate death surveillance systems in place that depend on death certificate data; the United States, Canada, and the nations of western Europe have led the way in creating useable death registration systems. Mortality data is collected, tabulated, and reported by organizations such as Statistics Canada and the (U.S.) National Center for Health Statistics, a branch of the CDC. These data sets are extraordinarily important for tracking disease causes and courses as well as other significant health care trends. However, they depend almost entirely on the information gathered by the funeral director and added to by the attending physician or medical examiner to establish such trends.
Death certificates generally list the full legal name of the deceased, the date and place of birth, the usual address of the deceased, names and birthplaces of the deceased’s parents, and a government-issued identification number such as a Social Security number. Additionally, the death certificate includes demographic information such as the decedent’s race/nationality, marital status, employment, and education.
The underlying and immediate causes of death as well as death’s manner (natural, accident, suicide, or homicide) are determined by a physician, coroner, or medical examiner; almost always, the coroner/medical examiner is involved determining the causes and manner when a death is suspected or known to have been caused by accident, suicide, or homicide. A medical examiner often conducts a post-mortem examination (autopsy) to make this determination.
While there are often several notations on the death certificate related to death’s cause, the underlying cause is defined as the disease or injury that initiated the events resulting in death and would include such statements as motor vehicle accident, cancer of the stomach, or congestive heart failure. For the purposes of mortality surveillance, this is the most important cause; it is aggregated with all other deaths to establish mortality data such as 25% of U.S. deaths and about 20% of Canadian deaths are the result of heart disease.
When death occurred under suspicious or unknown circumstances, the cause of death on the original certificate generally indicates that the death remains under investigation, listing the cause of death as “pending” or “deferred.” When drugs or alcohol are suspected to have contributed to the death, final determination of the cause must usually await the results of toxicology tests; in most jurisdictions, these analyses require at least two weeks to complete and often as long as six or seven weeks.
Some causes of death have multiple possible “manners” of death. For example, an opioid overdose could be the result of accident, suicide, or infrequently, homicide. In other words, the cause of death provides only the actual physiological mechanism of the death but it does not necessarily include the circumstances that caused that physiological mechanism to begin in the first place.
Funeral directors usually collect the personal data for the death certificate when initially meeting with families to talk about memorial arrangements. One advantage to pre-planning one’s funeral is that this data is already recorded by the “future deceased,” the person who likely knows this data best, saving family members from having to find information in the hours after a death. The kind of information that is often not known about older adults, for example, include such things as how long they have lived in the county or the names and birthplaces of the deceased’s own parents.
Certified copies of the death certificate are usually required to begin the process of settling or probating the deceased’s estate. After death, assets and liabilities in the deceased person’s name need to be transferred in an orderly fashion to other individuals or organizations in accordance with the deceased’s will, trust, or other estate plan. In order for family members to file claims for life insurance, Canada Pension, or Social Security, copies of the death certificate will certainly be required.
In addition to the need for death certification in establishing the facts of an individual’s death, the orderly collection of this data helps identify patterns of injury or disease in population groups. Links between environmental factors (such as type of employment) and disease are often spotted first in aggregated death certificate data. Because of the significant number of demographic factors reported, causes of death can be correlated with age, ethnicity, occupation, marital status, level of education, and geographical elements. While mistakes occur and not every death certificate accurately reports the deceased’s actual cause of death, epidemiologists believe the reporting is good enough to provide reliable population-level mortality data.
Enumerable examples illustrate how death certificate data is useful in research funding and policy development. The growth of HIV infection in the 1980s and the explosive opioid epidemic recently are two examples of how population-level data helps with identification and prevention activities.
Especially after a loved one died unexpectedly, individuals and families sometimes wait anxiously to see the cause of death on the death certificate; as explained above, they are often destined to wait many weeks before an official cause can be established. This uncertainty of the actual cause and circumstances, accompanied by questions of whether or not the deceased suffered, can greatly impact the course of early grief; not knowing the actual cause can prove even more difficult than knowing one’s loved one suffered significantly.
Clinicians and supportive professionals would serve their clients and patients well by inquiring what is known about the cause and circumstances of the death, whether the death certificate has been reviewed, and if not, an offer to review it with the patient. I have often found that the dread of knowing the facts is greater than learning the facts themselves and supportive professionals must be ready to help the bereaved negotiate this point.
Knowing death came from a specific cause often also fuels just the kind of motivation that lead to the establishment of foundations and organizations to promote mental health, to crusade against certain kinds of motor vehicle crashes, to provide advocacy for particular diseases, and to solicit contributions for research funds. Whether on a personal or social level, the death certification process is essential for much of the good that can be done in taking care of bereaved people.
Franklin, B. (1907). Smyth, Albert Henry (1907). The writings of Benjamin Franklin, Vol. X (1789-1790), edited by A. H. Smyth. New York, NY: MacMillian.
World Health Organization. (1979). Medical certification of cause of death. Geneva, Switzerland. WHO Publications. Retrieved from

The Author: For more than three decades, William G. Hoy has been counseling with the bereaved, supporting the dying and their families, and teaching colleagues how to provide effective care. After a career in congregation, hospice, and educational resource practice, he now holds a full-time teaching appointment as Clinical Professor of Medical Humanities at Baylor University in Waco, Texas.

Resource Review

If ever a website was made that could cover the sprawling, wide world of grief and bereavement - What’s Your Grief? - is it. This site offers quality bereavement materials, e-courses, and information on grief for both the griever and the professional. WYG’s blog is one of the great resources on their site, covering specific griefs, ideas on how to creatively memorialize our loved ones, and even providing easy-to-understand summaries of modern bereavement theories. If you give advice on bereavement or want a summary of the continuing bonds theory or the dual process model, this is the blog to visit.
Lastly, WYG takes care to look relevant; aware that an approachable aesthetic helps spread the truth and power of their message. This is a wonderful aspect of their materials because no one is embarrassed to pick up or hand out one of their pamphlets. The clean design matches the freshness of their approach to talking about grief and death and gives all of us a resource we can refer families to and reference ourselves with confidence.
In their own words, WYG offers the following to its online visitors:
  • Education that reaches beyond generalization
  • Practical and specific suggestions for moving forward
  • Modes of self-exploration and self-expression that suit all types of thinkers and doers
  • Ways to honor and remember deceased loved ones
  • A supportive community
I hope that you will consider this excellent resource moving forward for your patients, families, and yourselves.
Your Professional Library
Mannix, Kathryn. (2018). With the End in Mind: Dying, Death, and Wisdom in an Age of Denial.New York, NY: Little, Brown and Company.
Reviewed by Molly A. Keating, MA, CT
Editor, GriefPerspectives
The perspective of a cognitive behavioral therapist AND palliative care physician is a powerfully poised voice to speak into the question of what it means to die and just how we can best do that. With a focus on patterns she has observed over her career in the medical field, Dr. Kathryn Mannix is able to begin a conversation that seamlessly merges the physical experiences of birth and death, living and dying.
Utilizing her own experiences with terminal patients, Mannix tackles the spectrum of mindsets that she meets as a palliative care physician. From the man desiring assisted suicide (but could not and so died naturally) to the woman in complete and total “rock-solid” denial about her own death, Mannix illuminates with wisdom and gentleness the nuanced lessons these patients offered to her. There is also much to be observed and absorbed from her personal insight into the modern discourses surrounding death and where and how it takes place. Merging the physicality of palliative practice with modern psychological theories, Mannix is able to go beyond basic care to illustrate what the totality of care can mean for a broad spectrum of people.
Professionals and volunteers in the end-of-life arenas of care will undoubtedly feel buoyed by the spirit, compassion, and humanity that Mannix expresses and appreciates in each of her concise and excellently written chapters. It is often difficult to find voices that resonate with our experiences or echo our sentiments about the special, transformative importance of dying naturally.
The patterns that Mannix uses to support her conclusions are compelling and likely support or complete many of your own findings in this field. Finally, her conclusion helps to turn our heads up from the sadness of the stories encountered in death to the beautiful perspective and joy given to us because of the boundary that death imposes.
Molly Keating began a career in the funeral profession in 2009 and earned her Certificate in Thanatolgy in 2015. She works for a family-owned funeral home in Orange County, California where she lives with her husband and young daughter. She is thrilled to be a collaborator on GriefPerspectives and is passionate about modern grief education.
Research that Matters
Shapiro-Mendoza, C., Parks, S., Brustrom, J., Andrew, T., Camperlengo, L., Fudenberg, J., …Rhoda, D. (2017). Variations in cause-of-death determination for sudden unexpected infant deaths. Pediatrics, 140(1), e20170087. doi:10.1542/peds.2017-0087
Sudden unexpected infant deaths (SUIDS) are extraordinarily difficult to process for most parents, family members, and community friends. North American culture has largely turned a corner in infant and young child mortality so that children who leave the hospital healthy after delivery rarely die. When the unthinkable does occur, parents and caregivers need to understand what happened, whether they could have done anything to prevent the tragedy, and “what went wrong.” While making meaning of losses is a lifetime pursuit in grief, providing explanations to the cause of death can be meaningful to family members and to society at large if those findings can be translated into preventative strategies.
Expecting that coroners and medical examiners apply wildly different criteria and investigative procedures in establishing the cause of death of an otherwise-healthy infant, Shapiro-Mendoza and colleagues sought to understand how different medical examiners would rule on cause of death in three standardized death investigation scenarios. The researchers wrote, “Procedures routinely used to make a cause-of-death determination were highly consistent among survey respondents. It is encouraging that most ME/Cs reported using a combination of a death scene investigation, autopsy, and review of the medical record when making a cause-of-death determination for SUID, the 3 essential elements of a SUID investigation” (p. 5). The researchers also found that approximately 50% of the medical examiners/coroners completing the survey do not routinely use the term Sudden Infant Death Syndrome (SIDS) as a cause of death.

One concern about this last finding is that the actual incidence of SIDS could be underreported. While it was outside the scope of this project to investigate changes in the actual number of deaths from varied causes, the findings certainly raise the possibility that our common assumptions that SIDS deaths are declining in number could be based on flawed data. More research is needed to tease out the variables that could be at work in this finding in order to know how to appropriately conduct and fund research into varied causes of sudden unexpected infant death.
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