Death Certificate Template

June 8, 2011

A death certificate is official documentation regarding the death of an individual and it provides essential information about the deceased. Death certificates are legal requirements that contain information such as the individual’s identity and what is believed to have caused the person’s death. This death certificate template can be used to prepare a death certificate.
Sample Death Certificate Template

Certificate of Death

Number ……….

Name of the Deceased……….

Maiden Name …………………………

Gender ………………………..

Time of Death …………

Date ……………..

Birth Date ……………………………..

Place of Birth ………………………………………

Place where Death Occurred ………………………………

Name of Institution ……………………………….

City ………………………….

Country …………………………………….
Marital Status ………………………
Name of Spouse ……………….

Occupation of Deceased………………..

Residence …………………………..

Education Level ……………………………….
Name of Father …………………………..

Name of Mother ……………………….

Name of Informant …………………..

Funeral Facility ……………………

Signature …………………..

Cause of Death …………………………………………………..

Autopsy Report ……………………………………

Underlying Causes ………………………………………

Nature of Death ………………………………..

Certifier of Death ………………………………………

Date of Certification…………………..

License Number ……………………

Health Officer’s Signature…

 

Download Death Certificate Template in Word Format

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