Death certificate1_ _ _ _ _ _ Notary Office:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ This is to certify that: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
Hereby certify that
Filled by: _ _ _ _ _ _ _ _ _
Death Certificate 2 Death Certificate (Stub)
This is to certify that the resident, gender, address and ID number of the original jurisdiction died on, and the account was cancelled.
Hereby certify that
Organizer:
Police station (seal)
time
- .
proof of death
This is to certify that the resident, gender, address and ID number of the original jurisdiction died on, and the account was cancelled.
Hereby certify that
time
Death certificate 3 Entrusting unit
data source
(full name)
gender
age
nation
marital status
native place
address
occupation
level of education
identifier
Crime time
date month year
death time
date month year
Place of death
Provincial, municipal and district (county) street houses
die
die
origin
because
Direct/direct cause of death
Distance death
dead
About; In all parts of; about
space
time
I
middle
intervene
front
because
because
because
because
because
two
The root of death
Auxiliary cause of death
die
die
square
style
Natural war
Go and deal with this matter.
Self-killing euthanasia
Murder is uncertain.
Damage time
Year, month, day and hour
Injured site
Cause of injury
Signature of reference:
date month year
Official seal of the unit:
date month year
Remarks:
Instructions for Filling in Death Certificate 4 Supplementary Card of Maternal Death Registration Report
Number: compiled and filled in by the reporting unit.
Name: Fill in the name of the deceased. If the ID number is registered, the name should be consistent with the name on the ID card. Inside and outside the plan: refers to whether pregnancy and childbirth have a birth permit, those with a birth permit are planned, and those without a birth permit are unplanned. Education: The graduation education shall prevail. If you went to high school but didn't graduate, take junior high school education as the standard. Economic level: this item is an estimate, which refers to the per capita monthly income, that is, the annual per capita income of the family112. Residential area: "Mountain area" includes the mid-level area, and the dam area belongs to other projects.
Number of pregnancies: every pregnancy, regardless of the location and outcome of pregnancy, is counted as a pregnancy time. Including delivery after 28 weeks of pregnancy. Twins and multiple births are only one child. Twins and multiple pregnancies count as one child. The frequency of induced abortion and induced labor: including drug abortion, excluding natural abortion and incomplete abortion with curettage.
Last menstruation: fill in according to the Gregorian calendar date. If you are pregnant again in the future after abortion or childbirth, fill in 0; If the last menstrual period is ominous, fill in 9 on the date of the month, that is, September 99, 9999.
Delivery time: according to the Gregorian calendar date, the time must be filled in, according to the format of 00~23 o'clock; The ominous person fills in 99; If there is no delivery or abortion before 28 weeks, fill in 0 in this item.
Place of delivery: refers to the place where the pregnant woman is at the time of fetal delivery. If there is no delivery or abortion before 28 weeks, fill in 0 for this item, and fill in 9 for those who are unknown. Provincial (prefectural) hospitals refer to provincial, prefecture-level hospitals and equivalent military, factory and mine hospitals; County (district) hospitals refer to county hospitals and equivalent military, factory and mine hospitals; Township, town and street hospitals also include factories and mines at the same level. Death location: the type definition is the same as the delivery location.
Mode of delivery: Hip traction, fetal head suction, forceps, fetal destruction and varus all belong to the scope of vaginal surgery. New mode of delivery: refers to the fourth disinfection: that is, the delivery bag, the hands of the midwife, the vulva of the parturient and the umbilical cord of the baby are disinfected, and the delivery is carried out by doctors, midwives, trained primary health workers or trained midwives.
Midwives: medical personnel refer to doctors, nurses and midwives above township hospitals; Rural doctors refer to rural doctors or individual practitioners; Midwife means a trained midwife; Others refer to untrained midwives and their families, as well as the surrounding neighborhoods.
Prenatal check-up: If yes, please fill in the gestational age of the initial check-up and the number of prenatal check-ups during pregnancy.
Cause of death diagnosis basis: fill in according to the highest diagnosis basis. If there are both clinical diagnosis and pathological diagnosis, fill in the pathological diagnosis. Clinical diagnosis includes laboratory and other auxiliary examinations.
Evaluation results of medical institutions at all levels and main factors affecting death: this item is not filled in for the time being. However, after the local maternal death registration report card is audited, the audit results can be filled back into the supplementary card.
Death certificate 5 xx A notary office:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ This is to certify that: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
The city (or county) died of (cause of death).
Hereby certify that
Filled by: _ _ _ _ _ _ _ _ (signature)
Seal of relevant department:
date month year
Death certificate 6 death certificate
Medical record number: death certificate:
Note: If mistakes are found in the cause of death in the future, but the mistakes are inevitable at that time, the diagnostician will not bear legal responsibility. Note: 1. Please bring this certificate to the household registration office for death registration within 30 days after the death event occurs or is confirmed.
Two, in order to avoid unnecessary inheritance debt, attention should be paid to apply to the court for restriction or abandonment of inheritance within the time prescribed by law.
Death certificate 7 According to the requirements of the Notice on Further Regulating the Management of Medical Certificates and Information Registration of Population Death (National Health Planning [20xx] No.57), the health and family planning departments have the responsibility to issue death certificates. When family members declare to issue death certificates, they must bring the identity certificate of the deceased (household registration book, ID card), previous medical records, death certificates of neighborhood committees and other relevant certificates (certificates of public security and judicial organs, etc.). ). If the application materials do not meet the requirements, the health and family planning department has the right to refuse to issue a death certificate in principle. However, due to various reasons, the application materials do not meet the requirements, and family members really need death certificates to handle related matters. In line with the responsibility of "serving the people, serving the people", our unit has issued a medical inference of residents' death for the applicant to handle related matters. In this regard, the specific explanation is as follows:
1. Due to the lack of relevant supporting materials, it is impossible to judge whether the respondent died. Our unit only fills in relevant information according to the applicant's account number. If there is any judicial dispute in the future, it shall be borne by the applicant himself, which has nothing to do with our unit.
2. Because there is no medical information, our unit only fills in the medical inference of residents' death according to the' cause of death' described by the applicant, and the cause of death is not supported by any medical information. If there is any judicial dispute in the future, it shall be borne by the applicant and has nothing to do with our unit.
3. Because he died at home or other places, there was no medical information, and his family members did not report to the police, so it was impossible to clearly judge whether he died accidentally or because of illness. The cause of death is not supported by any clear information, and can only be described by the applicant. If there is any judicial dispute in the future, it shall be borne by the applicant and has nothing to do with our unit.
The applicant has read the above statement clearly and has no objection to all the contents of the statement. Hereby explain!
Name of the respondent:
applicant
Date:
Death Certificate 8 Chapter IV Attachment
Stub of death medical certificate
figure
Name and sex of the deceased 1 male 2 female 9 unknown.
If it is female, what kind of situation does it belong to:
1. Not pregnant within one year before her death. 2. Be pregnant when you die. 3. Not pregnant at the time of death, but pregnant within 42 days before death. 4. Not pregnant at the time of death, but pregnant within 43 days to one year before death. 5. You can't be sure whether you are pregnant within one year before your death.
nation
Main occupations and types of work
ID card number
The domicile of the street (township) in the province or city (county) where the household registration is located. The street (township) where the household registration is located in a province or city (county) is of sufficient age. The national identity card number is old enough. Marital status is 1. Unmarried 2 married 3 widowed 4 divorced 9 unknown household registration location.
Education level 1 University and above 2 middle schools 3 primary schools 4 illiterate or semi-illiterate 9 unknown
Work unit before death
Date of birth, date of death, date of death.
Exact age
Permanent address before death
Place of death
1 hospital ward 2 emergency room 3 families 4 on the way to the hospital 5 the names and contact numbers of foreign family members 9 are unknown.
Address or work unit of family members
The cause of death is the diagnosis of the main disease that causes death (please fill in the specific disease name, not the time interval from symptom appearance to death)
date of death
(a) A disease or condition that directly leads to death:
(b) The disease or condition leading to (a): MM DD YY.
(c) The disease or condition that caused (b): Name of family member (d) The disease or condition that caused (c):
And liaison office
Ⅱ*
Diagnosis of other diseases (promoting death, but not causing death)
Other important circumstances):
The doctor signed the above-mentioned diseases before the death of the deceased 1 provincial hospitals 2 prefecture-level hospitals 3 county-level hospitals.
The highest diagnostic unit: 4 hospitals, 5 village clinics, 6 did not see a doctor, and 9 other and unknown medical units stamped.
The highest diagnostic basis of the above diseases before death:
1 Autopsy 2 Pathology 3 Operation 4 Clinical+Physicochemical 5 Clinical 6 Inference 9 Unknown date after death
Resident signature
Medical unit seal
Year, month, day and death root cause: ICD code: Remarks:
Style on the back of death medical certificate: location of registered permanent residence
Permanent address before death
cause of death
Date of death year month day.
Name and contact office of the third family member
Signature of doctor and seal of medical unit
date month year
Seal of police station
date month year
Completion date year month day
fourfold
make it clear
This copy is kept by the issuing authority.
make it clear
This copy shall be kept by the household registration authority.
make it clear
1. Go to the crematorium for cremation with this certificate.
2. This certificate is invalid without the signature of the doctor and the seal of the medical unit and the police station.
1. If it is a female deceased, whether she was pregnant at the time of death or pregnant a year ago is very important for the calculation of maternal mortality.
2. Main occupation and job type: Fill in occupation and main job as much as possible. Such as: workers, farmers, cadres, students, soldiers, service industries, etc. ; You can also fill in the type of work in detail, such as lathe worker, fitter, electrician, textile worker, etc.
3. Permanent address: the address registered in the household registration book should be filled in completely, including the specific house number of the residence. 4. At least one year old: fill in according to one year old. If it is a baby, you can fill in the actual month, day and hour of survival. 5. Place of death: wards of medical institutions, including village clinics. Tick √ before the corresponding item.
6. The diagnosis of major diseases that lead to death can be divided into two parts: the first part (a) fill in the clinical manifestations of diseases that eventually lead to death, such as cor pulmonale, cerebral hemorrhage and skull fracture (do not fill in respiratory and circulatory failure); In (b), insert the disease or condition leading to (a); Such as emphysema, hypertension, external causes of trauma poisoning (collision between bicycle and car, suicide by jumping off a building, etc.). ); (c) Fill in the diseases or conditions that lead to (b), such as chronic bronchitis. Fill in other diseases or conditions that have nothing to do with the first part but have caused death in the second part.
7.ICD cause of death coding: Code the cause of death of the deceased according to the standard of the tenth edition of the International Classification of Diseases (ICD- 10), which shall be filled in by the reporting unit.
8. The highest diagnostic unit of diseases: generally refers to the last diagnostic unit of major diseases before death, and the highest diagnostic unit of diseases reported in Part I (a) can also be filled in. For example, provincial (city) hospitals include hospitals at or above the provincial level, and so on.
Attachment 1- 1: Supplementary Card for Maternal Death Registration Report
Supplementary card for maternal death registration report
(to be completed at the same time with the medical certificate of death of residents)
figure
Name and account 1. Local 2. Non-local 1 inside and outside the plan. Plan 2. Unplanned.
Education level 1. College degree or above. High school or technical secondary school. Junior high school 4. Primary school 5. Economic level 1. 200 yuan above 2. /kloc-more than 0/00 yuan 3. 50 yuan above 4. Living quarters below 50 yuan 1. Plain 2. Mountain area 3. Last menstrual delivery time in other areas.
Number of induced abortions and induced labor
Provinces, cities under the jurisdiction of provinces and districts (counties) of temporary residence
Place of delivery 1. 2 provincial (prefecture, city) hospitals. County (district) hospital. Township, town and street hospitals. Rural delivery room 5. Maternity home 6. On the way. Other 9. Unknown place of death 1. 2 provincial (prefecture, city) hospitals. County (district) hospital. Street hospital 4. Rural delivery room 5. Maternity home 6. On the way. Other 9. Unknown transfer mode 0. Unborn 1. Natural delivery 2. Vaginal surgery for delivery. A new method of cesarean section 1. It's two. number
Midwife 1. Medical staff 2. Country doctor 3. Midwife 4. Other personnel.
Prenatal examination 1. It's two. There were no prenatal examinations during the first pregnancy. Evaluation results of medical and health institutions at county (city, district) level 1. Avoidable 2. Creating conditions can avoid 3. The main factors that inevitably affect death 1 No.2 and No.3.
The evaluation result of municipal medical and health institutions is 1. Can be avoided. 2. You can avoid creating conditions. 3. The main factor that inevitably affects the number of deaths is 1. The doctor signs the card and the medical unit seals it.
Completion date year month day
Remarks:
Death certificate 9 scope and requirements of death certificate:
1. The hospital shall be responsible for issuing death certificates and reporting the deceased who died in our hospital, emergency or outpatient service. In addition, if a newborn dies, as long as there are vital signs at birth, a death certificate is required.
2. Our hospital 120 or 999 should be responsible for issuing a death certificate and reporting whether the deceased has vital signs after receiving a phone call from the family of the deceased.
3. The community health service center is responsible for issuing the death certificate and reporting the death of the resident population in the community health care area, but the applicant shall bring the following materials:
1) Description of the permanent residence and death facts of the deceased, with the official seal of the neighborhood committee or village committee where the permanent residence is located;
2) The original and photocopy of the identity certificate and residence booklet of the applicant and the deceased;
3) Proof of the relationship (other relationship) between the applicant and the deceased, such as household registration book, certificate of public security bureau, certificate of neighborhood committee or village committee, certificate of unit, etc.
4. In the process of issuing the death certificate, if the medical personnel suspect that the deceased died abnormally or the medical and health institutions cannot determine whether it is a normal death, the public security organ shall determine the nature of the death and issue a death certificate.
Death Certificate 10 First Issuing Unit
protect
shop
Medical certificate of death of residents
The third link
Preserved by the household registration management department.
Medical certificate of death of residents
The second copy is sent to the county CDC regularly, and the fourth copy is kept by the CDC.
The funeral management department let it live.
Medical certificate of death of residents
Death certificate 1 1
Medical certificate of death of residents
figure
record of investigation
Name of the deceased
gender
1 male and 2 female
If it is a female aged 13~49, ask her what kind of situation she belongs to: 1. Not pregnant within one year before her death. 3. Not pregnant at the time of death, but pregnant within 42 days before death. 4. Not pregnant at the time of death, but pregnant within 43 days to one year before death. I'm not sure if she was pregnant within one year before her death.
ID numbers of major ethnic occupations and types of work
History, symptoms and signs of the deceased:
Street (township) village (neighborhood committee) of the province, city and district (county) where the household registration is located.
Residential address: province, city, district (county), street (township) and village (neighborhood Committee)
Marital status 1 unmarried 2 married 3 widowed 4 divorced 9 unknown
Education level 1 University and above 2 middle schools 3 primary schools 4 illiterate or semi-illiterate 9 unknown
Work unit before death
Date of birth, date of death, date of death, age.
Location of death 1 hospital ward 2 emergency room 3 home 4 on the way to the hospital 5 foreign and other 9 unknown.
Names and telephone numbers of family members who can be contacted.
Address or work unit of family members
Diagnosis of major diseases leading to death (please fill in the name of specific diseases, not the symptoms and signs)
Time interval from onset to death
Ⅰ *
(a) A disease or condition that directly leads to death:
(b) The disease or condition leading to (a):
(c) The disease or condition leading to (b):
(d) The disease or condition leading to (c):
Ⅱ *
Diagnosis of other diseases (other important conditions that promote death but have nothing to do with death):
Name of the respondent
The deceased suffered from the above diseases before his death.
Highest diagnostic unit:
1 provincial hospitals 2 municipal hospitals 3 county hospitals
Four hospitals, five village clinics, six did not seek medical treatment, and nine others were unknown.
Relationship with the deceased
The highest diagnostic basis of the above diseases before death:
1 autopsy 2 pathology 3 surgery 4 clinical+physical and chemical 5 clinical 6 postmortem inference 9 unknown
Contact address or work unit
Resident signature
telephone number
Medical unit seal
Completion date year month day
Cause of death inference
Signature of researcher
Root cause of death: ICD code:
Date of survey year month day.
Remarks:
Death Certificate 12 "Medical Certificate of Cause of Death" is the legal certification material filled out by doctors for people who died due to illness and injury. It is kept by the public security department and the health department of China, and has dual purposes:
1. It is a population management record of residents' death, which records the basic information of the deceased and the cause of death. The public security department can cancel the account accordingly, and can also be used as a funeral and cremation department.
The basis of corpse incineration.
2. It is the original data record of the cause of death statistics, and the health department can calculate a series of death statistics indicators based on it, so as to carry out special research on the health status of residents, put forward public health problems that need to be solved first, and provide reliable basis for formulating corresponding prevention and control measures.
3 can be submitted to the public security and judicial departments as a legal evidence.
4. At present, it is increasingly used for popular and socialized vouchers such as insurance, inheritance and death notarization.
It is worth noting that the medical certificate of the cause of death is only valid after it is stamped with the official seal of the medical unit.
Four, China medical proof of the cause of death.
The Medical Certificate of Death of China Residents was officially issued by the Ministry of Health on August 1990, and all parts of the country were notified to follow it (see attached table). 1992 Three ministries jointly issued a document (Ministry of Health, Ministry of Public Security and Ministry of Civil Affairs) reaffirming the format of medical certificate of death in China. The core part of medical death certificate adopted in China completely adopts the basic format of International Medical Death Certificate. The rest, try to keep and absorb the reasonable part of the death report (card) used before in all parts of China. The medical certificate of death used by China is in quadruplicate. The first copy is the stub of the issuing unit; The second copy is used for computer entry, and the issuing unit directly submits it to the local county (district) disease control institution; Third, the household registration management department cancels the household registration certificate; The fourth is the evidence of funeral and cremation. The style of each couplet is as follows: