La. Admin. Code tit. 48 § V-12307

Current through Register Vol. 50, No. 11, November 20, 2024

Section V-12307 - Certificate of Death Preparation

A. Section-Personal Data of Deceased

1. Last Name (Item 1A). Enter the surname of the deceased. Identifications, e.g., Jr. II, III, etc., shall appear immediately following and as a part of the surname. The surname of a married women may be either her maiden name or that of her husband.

2. First Name Enter the first name of the deceased.

3. Second Name Enter the second name of the deceased. If the name is not known or cannot be determined, enter "unknown".

4. Date of Death.

a. Enter the month, day and year using the following abbreviations: Jan., Feb., Mar., Apr., Aug., Sept., Oct., Nov., and Dec.

b. Enter the complete spelling for the months of May, June and July.

5. Hour of Death. Enter the hour of death indicating A.M. or P.M. If the institution operates on 24 hour or military time, the hour of death may be so expressed.

6. Sex Enter male or female.

7. Color or Race. Enter race as provided by informant, e.g., White, Black, American Indian (indicate tribe if known). For non-white groups other than black or American Indian, enter the national origin, e.g., Chinese, Japanese, Puerto Rican, etc. Generic designations of Oriental, Polynesian, European, etc., are not acceptable.

8. Marital Status Check the appropriate blank.

9. Surviving Spouse. If the decedent was legally married at death, enter the name (maiden name in the case of a widow) of the survivor. If the deceased was single at death, enter "none."

10. Date of Birth of Deceased. Enter the month, day and year per instructions for Item 2A. If the birthdays is not known, enter "unknown" in full. If the birth date represents an approximation, enter birth date as "Approx." then date, example "Approx. Mar. 12, 1935."

11. Age of Deceased. Enter the age of the deceased in years, months and days. If the exact information is not known, enter an approximation of age. If the deceased was under 24 hours old, enter hours and minutes. Place dashes (-) in blocks that are not applicable.

12. Birthplace. Enter the city and state if full. If the deceased was born outside of the United States, enter the name of country in full.

13. Citizen of What Country. If the deceased was a citizen of the United States, enter "U.S.A." Enter the name of the country in full if deceased was not a citizen of the United States. If citizenship is not known, enter "unknown."

14. Usual Occupation. Notwithstanding the decedent's occupation at the time of death or that the deceased was retired, enter the type of occupation performed during the longest period of his/her working life. If the deceased had never been employed, enter "never employed." Enter "unknown" if the information is not available.If the deceased was under 14 years of age, a dash (-) should be entered.

15. Kind of Business or Industry. Enter as specifically as possible the kind of business or industry in which the deceased was employed. Do not enter the name of the company. Avoid unclear designations, e.g., "factory" or "mill." Instead enter "paint factory" or "saw mill."

16. Ever in U.S. Armed Forces? Check the appropriate block.

17. Social Security Number. Enter the Social Security Number; if it is not known, enter "unknown."

B. Section-Place of Death

1. City, Town, or Location of Death. Enter the full name of city, town or location where death occurred, regardless of size.

2. Parish of Death. Enter the name of parish in full.

3. Name of Hospital or Institution. If death occurred in a hospital or institution, enter the name of the facility. If death did not occur in a hospital or institution, enter the street address or otherwise enter location.

4. Death in Hospital. Complete this item only if death occurred in a hospital; check the appropriate block.

5. Is Place of Death Inside City Limits? Check "yes" or "no" as appropriate.

C. Section-Usual Residence of Deceased

1. City, Town or Location. Enter the city, town or location of usual residence.

2. Parish. Enter the name of the parish of usual residence.

3. State. Enter the name of the state in full.

4. Street Address. Enter the street address of the urban community or location, if rural.

5. If Residence Inside City Limits? Check "yes" or "no" as appropriate.

D. Section-Parents

1. Father's Name. The name of the father shall refer to the husband of the mother of the deceased, unless the biological father had formally acknowledged or legitimated the deceased prior to his/her death. Enter the last, first and second name of the father; if not known, enter "unknown."

2. Father's Place of Birth. If the father was born in the United States, enter the city and state. If born outside the United States, enter the name of that country in full. If the father's place of birth is not known, enter "unknown."

3. Mother's Maiden Name. Enter the last, first and second name of the mother. If the name is not known, enter "unknown."

4. Mother's Place of Birth. If the mother was born in the United Stated, enter the city and state. If born outside the United States, enter the name of that country in full.

E. Section-Informant's Certification

1. Signature and Address of Informant

a. The signature and address of the person providing information contained in Items 1A through 15B should appear in this space. If the informant is unable to write, his "X" and two witnesses are required. The informant shall limit his signature to the space provided.

b. In the event information is taken from institutional records, the entry shall read "Hospital (or name of institution) Records" and be signed by the custodian of those records.

c. Another person may sign the informant's name with permission as follows: John Doe/initials of the third party.

2. Date of Signature. Enter the date of signature in Item 16A.

F. Section-Cause of Death

This section is to be completed only by the attending physician or coroner certifying in H.2 (Item 21A)

1. Death was Caused By:

(A). Immediate Cause. Enter the disease or condition which cause death.

(B) and (C)Due to or as a consequence of:

i. Enter on these lines in appropriate sequence those causes, if any, in existence prior to death which may have given rise to the cause entered in (A).If (B) and (C) do not apply, enter "none" or leave blank. For each cause appearing on lines (A), (B) or (C) use as accurate terminology as is possible. Approximate internals between onset of the cause and death.

2. Other Significant Conditions

a. Enter any other conditions unrelated to those appearing in part I that contributed unfavorable to the fatal outcome.

b. Example: A complication of pregnancy might be reported in part I. But, if pregnancy was without complication and within 3 months of the date of death, it should be reported in Part II.

3. Autopsy. Check "yes" or "no" as appropriate.

4. If yes-Complete this item only if yes is checked in Item 18A.

G. Section-Death Due to External Violence

1. Complete this section only for deaths due to other than natural causes.

2. Describe How Injury Occurred. Enter the nature and description of the injury if injury appears in Part I or II of Item 17.

3. Time of Injury. Enter the time and date of injury, if applicable.

4. Injury Occurred. If applicable, indicate whether the injury occurred on or off the job.

5. Place of Injury. Specify where the injury occurred, if applicable.

6. If appropriate, enter the street address or location, city and state where the injury occurred.

H. Section-Physician's Certification

1. Certification (Attendance). Enter dates of medical attendance of the deceased.

2. Signature and Address of Physician.

a. The person legally responsible, physician or coroner, shall personally sign in this space in permanent black ink indicating professional status, i.e., M.D. or Coroner. The physician or coroner shall limit his signature to the space provided. Enter the address of the signatory.

NOTE: This section shall only be completed by the attending physician or coroner (including assistants) certifying death. No one else may sign for him and facsimiles or stamps shall not be acceptable.

b. If accident, suicide or homicide is checked, the signature shall be that of the coroner or his assistant in the parish where death due to external violence occurred.

3. Date. Enter date Item 21A was completed.

I. Section-Funeral Director: Certification. Immediately below the word "Certification" enter the funeral director's facility license number. This is in addition to the license number to appear in Item 23B. If a person other than a funeral director is managing the body of the deceased, enter "not applicable" in this space.

1. Enter the manner of disposal and the date thereof.

2. Name and Location. Enter the official name and address or location, including city or location and state of the cemetery or crematory where final disposition is to be made.

3. Signature and Address of Funeral Director. The person authorized to act in the name of the funeral director, or other person managing the body shall sign in black, permanent ink and include the business address.

4. License Number. Enter the Embalmer's license number. If the body is not embalmed, enter "not applicable."

J. Section-Burial Transit Permit Number

1. Burial Transit Permit Number

a. The number of the burial-transit permit issued is entered here by the person issuing the permit at the time of issuance.

b. Note that permits are to be issued only upon presentation of a properly completed death certificate. However, if a funeral director presents a death certificate completed to the limits of his ability and resources and for reasons beyond his control he is unable to present an entirely completed death certificate, a permit shall be issued. The permit is issued with the provision and understanding that the funeral director will present a completed document as soon as humanly possible. In the event that the funeral director abuses his privilege, the privilege is to be withdrawn.

2. Parish of Issue. Enter the parish name in full where the permit was issued.

3. Date of Issued. Enter the date the permit was issued.

4. Signature of Local Registrar. Enter the name of the Local Registrar of the parish where the certificate is filed. The signature shall be in permanent black ink.

La. Admin. Code tit. 48, § V-12307

Promulgated by the Department of Health and Human Resources, Office of Preventive and Public Health Services, LR 13:246 (April 1987).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:32 et seq.