NYC DEATH CERTIFICATE WORKSHEET

Dear Informant,


The New York City Department of Health and Mental Hygiene (NYC Health Department) issues death certificates for all people who die in one of the five boroughs of NYC. As the Informant, you are providing personal information about the deceased, referred to here as the Decedent. Both public health and medicine rely on complete and accurate data about the Decedent.


This information is valuable for understanding the health of New Yorkers, including causes of death, through personal information such as race and borough of residence. It also helps create programs to prevent illness and death. It is important that you provide complete and accurate information for all the questions. 

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Decedent

Where was the Decedent born? Enter the Decedent’s birthplace. If the Decedent was born in the U.S. or Canada, also include the state or province. For other countries, you are not required to list a city or state. Enter the country name as it exists now or existed at the time of the Decedent’s birth. If none of this information is known and cannot be obtained, enter “Unknown.” 

Decedent's Residence: The residence is the actual address of the place where the Decedent lived. Do not enter a post office box or other address used for mailing purposes only. Enter the state or province if the country is the U.S. or Canada. This information is used to understand the health of neighborhoods and evaluate the availability and use of services by neighborhoods.

FAMILY INFORMATION

Informant: Print the Informant’s name exactly as you want it to appear on the death certificate. Separate the first, middle and last names in the boxes below. The Informant should not be the Decedent. 

If yes, skip to the phone and email. If no, enter the name of the Authorizer below.

FINAL DIPOSITION

Will you be requesting a City Burial for the Decedent? City Burial is when the Office of the Chief Medical Examiner buries the Decedent at the City Cemetery on Hart Island. This serves as NYC’s public cemetery. 

If no, complete the fields below. If yes, skip to the Occupation and Industry section.

Occupation and Industry: Information about the Decedent’s job helps the NYC Health Department learn more about how certain occupations and industries may affect health and create policies to protect such groups of workers. Certain job conditions, such as exposures to toxic paints and chemicals and high-stress industries, may affect health and be linked to certain health conditions. 


How to provide the best information:

  • The Decedent may have had many different occupations and places of business during their life. Report the job the Decedent worked at the longest.
  • If the Decedent was younger than age 14, enter “Infant” or “Child” for both items.
  • If the Decedent was a student and unemployed, enter “Student” as their occupation and the type of school (such as “High School” or “College”) as their industry.
  • If the Decedent was retired or unemployed, enter the kind of work done they did during most of their life.
  • If the Decedent was a homemaker, enter “Homemaker” as their occupation and “Own Home” as their industry. 
  • If the Decedent was not a student or homemaker and never worked during their life, enter
  • “Never Worked” for both fields. 

Education: Information about the Decedent’s education helps researchers understand trends in age and education levels in NYC residents, reading level required for health education materials, health information needs, and other factors that may affect health. 

Ancestry and Race: Ancestry refers to the country where their ancestors (parents, grandparents or greatgrandparents) were born. If they were born in the U.S. but have ancestors that were born in different countries, all those places may be part of their ancestry. Information on ancestry helps researchers understand more about genetic conditions, cultures, and locations of existing and new ethnic communities that may affect the availability of quality care services and medical programs.

Race is a way to group people who come from similar countries and share cultural practices or physical characteristics. Information about race helps researchers understand more about death rates, health conditions and other factors relating to race that affect health service needs in NYC.

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