Death Certificate Questions (with Solutions)
By MBBS GANG
Q1) Prepare a Medical Certificate of Cause of Death based on the following problem:
A 52-year-old male had 10-year history of chronic bronchitis associated with heavy smoking. He was on
corticosteroids and bronchodilators for last 3 years. In one evening, he complained coughing and
gradually worsening shortness of breath. He was taken to the emergency department of nearest
hospital and acute exacerbation of chronic obstructive lung disease was diagnosed. He was admitted
in the hospital and treated accordingly. But he could not be recovered and died after 8 hours of
admission.
Q2) Prepare a Medical Certificate of Cause of Death based on the following problem:
A 58-year-old male presented with complaint of haemoptysis for long duration and loss of weight. On
examination, he was found anaemic and was admitted in the hospital in the morning. Advanced
pulmonary tuberculosis reactivation type with cavitation was diagnosed in the afternoon. The patient
also gave history of atherosclerosis and varicose vein of lower limbs. In the same evening, the patient
had active massive pulmonary haemorrhage and died on the same day.
Q3) Prepare a Medical Certificate of Cause of Death based on the following problem:
On 3rd January, a 60-year-old female was admitted with a strangulated femoral hernia which started 4
days earlier. She came complaining of abdominal pain and fecal vomits. Apparently, the small intestine
was perforated even before. On 4th January, she underwent a release of the hernia and resection-
anastomosis of the small intestines. On 5th January, she started developing signs of peritonitis. She
died on 14th January.
Q4) Prepare a Medical Certificate of Cause of Death based on the following problem:
A 63-year-old male had been treated for some years for malignant hypertension and developed
hypertensive heart disease. He presented with abdominal pain in one afternoon and appendicitis
was diagnosed. Appendicectomy was done in the same evening and he recovered successfully after
that. After 3 weeks, he developed congestive cardiac failure and he died.
Q5) Prepare a Medical Certificate of Cause of Death based on the following problem:
A 75-year-old male was admitted to the hospital with severe chest pain. On admission, ECG &
echocardiography was done which was diagnostic of acute anterior wall myocardial infarction. He had
a history of arteriosclerotic heart disease with ECG findings of ischemia for last 10 years. He died after
3 hours of admission.
FORM NO.4
(See Rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(Hospital in patients. Not to be used for stillbirths)
To be sent to Registrar along with From No.2 (Death Report)
Name of the Hospital: Calcutta National Medical College and Hospital
I hereby certify that the person whose particulars are given below died in the
hospital in ward No CNM-2 on 1.01.2020 at 12:47 A.M.
NAME OF DECEASED: HARTOSH SINGH For use of
Age at Death Statistical
If 1 year or If less than 1 If less than one If less than one Office
Sex
more, age in year, age in month, age in days day, age in Hours
years Months
1. Male
2. Female 52
CAUSE OF DEATH Interval between
onset & death
Approx
(a) Acute (For
I. Immediate cause
8 hrs registration
State the disease, injury or complication exacerbation of
which Caused death, not the mode of dying using
COPD due to (or as
such as Heart failure, asthenia, etc. consequences of) International
Classification
Antecedent cause (b) Chronic of Diseases.
Morbid conditions, if any, giving rise to the Bronchitis from 10 years ICD-11, in
Heavy Smoking due effect from
above Cause, stating underlying conditions
to (or as 1st Jan, 2022
last consequences of)
has specific
(c) coding
II. numbers for
various
Other Significant conditions contributing to the conditions.)
Death but not related to the diseases or conditions
causing it.
Manner of Death
1. Natural 2. Accident 3. Suicide 4. Homicide How did the injury occur?
5. Pending Investigation
If deceased was a female, was pregnancy the 1. Yes 2. No
death associated with?
If yes, was there a delivery? 1. Yes 2. No
Name and Signature of the Medical Attendant certifying the Cause of Death.
Date of Verification: Dr. Sandeep Bakshi, Reg No: 12345, 01.01.2020
SEE REVERSE FOR INSTRUCTIONS
(To be detached and handed over to the relative of the
deceased)
Certified that Shri/Smt/Kum Hartosh Singh S/W/D of Shri Gurbaksh Singh, R/O Jhargram was
admitted to this hospital on 31.12.2019 and expired on 01.01.2020 at 12:47 am, the cause of death
being acute exacerbation of COPD.
Doctor: Nabanita Ray
(Medical Supdt.Name of Hospital)
FORM NO.4
(See Rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(Hospital in patients. Not to be used for stillbirths)
To be sent to Registrar along with From No.2 (Death Report)
Name of the Hospital: Calcutta National Medical College and Hospital
I hereby certify that the person whose particulars are given below died in the
hospital in ward No Male-7 on 04.03.2021 at 6:05 P.M
NAME OF DECEASED: PALLAB SANYAL For use of
Age at Death Statistical
If 1 year or If less than 1 If less than one If less than one Office
Sex
more, age in year, age in month, age in days day, age in Hours
years Months
1. Male
2. Female 58
CAUSE OF DEATH Interval between
onset & death
Approx
(a) Acute Massive (For
I. Immediate cause
8 hrs registration
State the disease, injury or complication Pulmonary
which Caused death, not the mode of dying using
Hemorrhage
such as Heart failure, asthenia, etc. due to (or as International
consequences of) Classification
Antecedent cause of Diseases.
(b) Advanced ICD-11, in
Morbid conditions, if any, giving rise to the 6 Months
Pulmonary effect from
above Cause, stating underlying conditions Tuberculosis due to 1st Jan, 2022
last (or as consequences
of)
has specific
coding
numbers for
II.
various
Other Significant conditions contributing to the
Atherosclerosis, conditions.)
Varicose Veins of 10 years
Death but not related to the diseases or conditions
causing it. Lower Limbs
Manner of Death
1. Natural 2. Accident 3. Suicide 4. Homicide How did the injury occur?
5. Pending Investigation
If deceased was a female, was pregnancy the 1. Yes 2. No
death associated with?
If yes, was there a delivery? 1. Yes 2. No
Name and Signature of the Medical Attendant certifying the Cause of Death.
Date of Verification: Dr. Sandeep Bakshi, Reg No: 12345, 04.03.2021
SEE REVERSE FOR INSTRUCTIONS
(To be detached and handed over to the relative of the
deceased)
Certified that Shri/Smt/Kum Pallab Sanyal S/W/D of Shri Biswajit Sanyal, R/O Jhargram was
admitted to this hospital on 04.03.2021 and expired on 04.03.2021 at 6:05 pm, the cause of death
being acute massive pulmonary hemorrhage.
Doctor: Nabanita Ray
(Medical Supdt.Name of Hospital)
FORM NO.4
(See Rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(Hospital in patients. Not to be used for stillbirths)
To be sent to Registrar along with From No.2 (Death Report)
Name of the Hospital: Calcutta National Medical College and Hospital
I hereby certify that the person whose particulars are given below died in the
hospital in ward No Female- 17 on 14.01.2022 at 5:36 P.M.
NAME OF DECEASED: CHAMPA MANDAL For use of
Age at Death Statistical
If 1 year or If less than 1 If less than one If less than one Office
Sex
more, age in year, age in month, age in days day, age in Hours
years Months
1. Male
2. Female 60
CAUSE OF DEATH Interval between
onset & death
Approx
(a) Peritonitis (For
I. Immediate cause
State the disease, injury or complication due to (or as 9 Days registration
which Caused death, not the mode of dying consequences of) using
such as Heart failure, asthenia, etc. International
(b) Small Intestine Classification
Perforation due to 10 Days
Antecedent cause of Diseases.
(or as consequences
Morbid conditions, if any, giving rise to the of) ICD-11, in
effect from
above Cause, stating underlying conditions
last. (c) Strangulated 1st Jan, 2022
15 Days has specific
Femoral Hernia
coding
numbers for
II.
various
conditions.)
Other Significant conditions contributing to the
Death but not related to the diseases or conditions
causing it.
Manner of Death
1. Natural 2. Accident 3. Suicide 4. Homicide How did the injury occur?
5. Pending Investigation
If deceased was a female, was pregnancy the 1. Yes 2. No
death associated with?
If yes, was there a delivery? 1. Yes 2. No
Name and Signature of the Medical Attendant certifying the Cause of Death.
Date of Verification: Dr. Sandeep Bakshi, Reg No: 12345, 14.01.2022
SEE REVERSE FOR INSTRUCTIONS
(To be detached and handed over to the relative of the
deceased)
Certified that Shri/Smt/Kum Champa Mandal S/W/D of Shri Ratan Mandal, R/O Jhargram was
admitted to this hospital on 03.01.2022 and expired on 14.01.2022 at 5:36 pm, the cause of death
being peritonitis.
Doctor: Nabanita Ray
(Medical Supdt.Name of Hospital)
FORM NO.4
(See Rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(Hospital in patients. Not to be used for stillbirths)
To be sent to Registrar along with From No.2 (Death Report)
Name of the Hospital: Jawaharlal Nehru Medical College, Kalyani
I hereby certify that the person whose particulars are given below died in the
hospital in ward No Male-7 on 5.5.2022 at 2:32 P.M
NAME OF DECEASED: Abby Philips For use of
Age at Death Statistical
If 1 year or If less than 1 If less than one If less than one Office
Sex
more, age in year, age in month, age in days day, age in Hours
years Months
1. Male
2. Female 63
CAUSE OF DEATH Interval between
onset & death
Approx
(a) Sudden Cardiac (For
I. Immediate cause
State the disease, injury or complication Death from 1 hr registration
which Caused death, not the mode of dying Ventricular using
such as Heart failure, asthenia, etc. Tachycardia due International
to (or as Classification
Antecedent cause consequences of) of Diseases.
Morbid conditions, if any, giving rise to the ICD-11, in
(b) Hypertensive
effect from
above Cause, stating underlying conditions Heart Disease due to 1 Year
(or as consequences 1st Jan, 2022
last has specific
of)
coding
(c) Malignant 5 Yrs numbers for
II.
Hypertension various
Other Significant conditions contributing to the conditions.)
Death but not related to the diseases or conditions
causing it.
Manner of Death
1. Natural 2. Accident 3. Suicide 4. Homicide How did the injury occur?
5. Pending Investigation
If deceased was a female, was pregnancy the 1. Yes 2. No
death associated with?
If yes, was there a delivery? 1. Yes 2. No
Name and Signature of the Medical Attendant certifying the Cause of Death.
Date of Verification: Dr. Sandeep Bakshi, Reg No: 12345, 5.5.2022
SEE REVERSE FOR INSTRUCTIONS
(To be detached and handed over to the relative of the
deceased)
Certified that Shri/Smt/Kum Abby Philips S/W/D of Shri Joseph Philips, R/O Jhargram was
admitted to this hospital on 18.4.2022 and expired on 5.5.2022 at 2:32 pm, the cause of death being
sudden cardiac death from ventricular tachycardia.
Doctor: Nabanita Ray
(Medical Supdt.Name of Hospital)
FORM NO.4
(See Rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(Hospital in patients. Not to be used for stillbirths)
To be sent to Registrar along with From No.2 (Death Report)
Name of the Hospital: Jawaharlal Nehru Medical College, Kalyani
I hereby certify that the person whose particulars are given below died in the
hospital in ward No JMN-13 on 10.12.2022 at 7:49 P.M
NAME OF DECEASED: AJIT PYNE For use of
Age at Death Statistical
If 1 year or If less than 1 If less than one If less than one Office
Sex
more, age in year, age in month, age in days day, age in Hours
years Months
3. Male
4. Female 75
CAUSE OF DEATH Interval between
onset & death
Approx
(a) Cardiogenic Shock (For
I. Immediate cause
State the disease, injury or complication due to (or as registration
which Caused death, not the mode of dying consequences of) 3 hrs using
such as Heart failure, asthenia, etc. International
(b) Acute Myocardial
Classification
Infarction due to (or
Antecedent cause as consequences of) of Diseases.
Morbid conditions, if any, giving rise to the ICD-11, in
(c) Athero-Sclerotic effect from
above Cause, stating underlying conditions 10 Years
Cardio-vascular 1st Jan, 2022
last has specific
disease (AS-CVD)
coding
numbers for
II.
various
Other Significant conditions contributing to the conditions.)
Death but not related to the diseases or conditions
causing it.
Manner of Death
1. Natural 2. Accident 3. Suicide 4. Homicide How did the injury occur?
5. Pending Investigation
If deceased was a female, was pregnancy the 1. Yes 2. No
death associated with?
If yes, was there a delivery? 1. Yes 2. No
Name and Signature of the Medical Attendant certifying the Cause of Death.
Date of Verification: Dr. Sandeep Bakshi, Reg No: 12345, 10.12.2022
SEE REVERSE FOR INSTRUCTIONS
(To be detached and handed over to the relative of the
deceased)
Certified that Shri/Smt/Kum Ajit Pyne S/W/D of Shri Nirmal Pyne, R/O Jhargram was admitted to
this hospital on 10.12.2022 and expired on 10.12.2022 at 7:49 pm, the cause of death being
cardiogenic shock.
Doctor: Nabanita Ray
(Medical Supdt.Name of Hospital)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
Directions for completing the form
Name of deceased: To be give in full. Do not use initials. If deceased is an infant, not yet named at
time of death, write ‘Son of (S/o)’ or ‘Daughter of (D/o)’, followed by names of mother and father.
Age: If the deceased was over 1 year of age, give age in completed years. If the deceased was below 1
year of age, give age in months and if below 1 month give age in completed number of days, and if below
one day, in hours.
Cause of Deaths: This part of the form should always be completed by the attending physician
personally.
The certificate of cause of death is divided into two parts, I and II. Part I is again divided into three
parts, lines (a) (b) (c). If a single morbid condition completely explains the deaths, then this will be
written on line (a) of Part I, and nothing more need be written in the rest of Part I or in Part II, for
example, smallpox, lobar pneumonia, cardiac beriberi, are sufficient cause of death and usually nothing
more is needed.
Often, however, a number of morbid conditions will have been present at death, and the doctor must
then complete the certificate in the proper manner so that the correct underlying cause will be
tabulated. First, enter in Part I(a) the immediate cause of death. This does not mean the mode of
dying, e.g., heart failure, respiratory failure, etc. These terms should not be appear on the certificate
at all since they are modes of dying and not causes of death. Next consider whether the immediate
cause is a complication or delayed result of some other cause. If so, enter the antecedent cause in Part
I, line(b). Sometimes there will be three stages in the course of events leading to death. If so, line (c) will
be completed. The underlying cause to be tabulated is always written in last in Part I.
Morbid conditions or injuries may be present which were not directly related to the train of events
causing death but which contributed in some way to the fatal outcome. Sometimes the doctor finds it
difficult to decide, especially for infant deaths, which of several independent conditions was the primary
cause of death; but only one cause can be tabulated, so the doctor must decide. If the other diseases
are not effects of the underlying cause, they are entered in Part II.
Do not write two or more conditions on a single line. Please write the names of the diseases (in full) in
the certificates as legibly as possible to avoid the rise of their being misread.
Onset: Complete the column for interval between onset and death whenever possible, even if very
approximately, e.g., “from birth” “several years”.
Accidental or violent deaths: Both the external cause and the nature of the injury are needed and
should be stated. The doctor or hospital should always be able to describe the injury, stating the part
of the body injured, and should give the external cause in full when this is shown. Example: (a)
Hypostatic pneumonia; (b) Fracture of neck of femur; (c) Fall from ladder at home.
Maternal deaths: Be sure to answer the question on pregnancy and delivery. This information is needed
for all women of child-bearing age, even though the pregnancy may have had nothing to do with the
death.
Old age or senility: Old age (or senility) should not be given as a cause of death if a more specific cause
is known. If old age was a contributory factor, it should be entered in Part II. Example: (a) Chronic
bronchitis, II old age.
Completeness of information: A complete case history is not wanted, but, if the information is
available, enough details should be given to enable the underlying cause to be properly classified.
Example: Anaemia – Give type of anaemia, if known. Neoplasm – Indicate whether benign or malignant,
and site, with site of primary neoplasm, whenever possible, Hear disease – Describe the condition
specifically; if congestive heart failure, chronic on pulmonale, etc., are mentioned, give the antecedent
conditions. Tetanus – Describe the antecedent injury, if known. Operation – State the condition for
which the operation was performed. Dysentery – Specify whether bacillary, amoebic, etc., if known.
Complications of pregnancy or delivery – Describe the complication specifically, Tuberculosis – Give
organs affected.
Symptomatic statement: Convulsions, diarrhea, fever, ascites, jaundice, debility, etc., are symptoms
which may be due to any one of a number of different conditions. Sometimes nothing more is known,
but whenever possible, give the disease which caused the symptom.
Manner of Death: Deaths not due to external cause should be identified as ‘Natural’. If the cause of
death is known, but it is not known whether it was the result of an accident, suicide or homicide and
is subject to further investigation, the cause of death should invariably be filled in and the manner of
death should be shown as ‘Pending investigation’.
