Five Centuries of Death Certificates

Reprinted with permission from the October 18, 2018, edition of the Memorial Business Journal, a publication of the National Funeral Directors Association.  Written by Carol Milano.  Photo Credit:  By Simon Burchell – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=11393051

You could say death certificates were born in 1538 when the Anglican Church decided that births, marriages and deaths should be recorded in parish registers. Until that time, it was easiest to discover a death by absence; documents might refer to a man in the past tense, for example, or his name would no longer appear on lists of jurors or witnesses.

Even for the wealthy, the recording of death was relatively unimportant. When someone died, the last will and testament became authoritative, rather than any actual death record. In England, the British government displayed great interest in wills, possibly as a source of fines or land. Because civil courts had the final say in any disputed cases, references to the deceased and his property can be found easily.

Before 1538, deaths might have been noted in church service books, missals, Psalters, chanceries or heraldic records. For richer individuals, legal information related to a death could be found in probates, coroners’ records and postmortem inquisitions. The less affluent often died anonymously.  Throughout Europe, though, more records can be found about the very poor than about the rich. Since everyone had to be buried somewhere, local authorities often arranged with churches to bury the poor.

In the 16th century, under “poor laws,” churchwardens collected alms from a parish’s wealthier members and used the money to build poorhouses. The indigent, if buried in consecrated ground, received quick, anonymous burials, sometimes in mass graves to reduce expenses. Any churchyard burials were probably due to a priest’s kindness. In England, more early data exist on criminals than on law-abiding citizens, especially if they were hanged; there were court records of the trial and execution date.

The first American settlers applied British laws and customs to the recording of deaths. Before 1800, churches maintained burial records for congregants throughout the Colonies. Most early American death information is found only in church records.  Eventually, some Colonies required churches to report death events to civil authorities; some locations have both civil and church historic records. Several Colonies, mainly in New England, actually enacted laws requiring local governments to record and maintain death certificates.

By the 19th century, many British and European countries were maintaining death certificates at the national level. The United States, however, has never created a national registry and was slow to establish government mandates for death certificate regulation. Before 1880, only 14 states (and five cities) needed death certificate registration. Most states didn’t require it until after 1900. Because registration laws were passed at different times, today, states have different information requirements for death certificates.

USES FOR DEATH CERTIFICATES

Based on an international form adopted in 1948, then modified in the 1990s, the United States has three types of death certificates:

• Standard
• Medical or legal case
• Fetal or stillborn death.

The form usually lists the immediate cause of death, the conditions that led to it and any significantcant medical factors, such as diabetes. The manner of death is also recorded, with space for indicating that the cause of death could not be determined or the investigation is pending. “Pending” status permits time for further medical examination while allowing for a funeral.

Death certificates are also a vital public health tool. They help set public health goals and policies, identify emerging public health threats and determine which medical conditions will receive government funding. Public health departments review death certificates to find patterns that could pinpoint a problem. A cluster of cancers in one geographic area might help lead to the discovery of an unknown toxic site, for instance.

For centuries, death certificate mortality data have been the best, and sometimes only, source of information about life-threatening illnesses. In Italy, for example, death certificate analyses guide allocation of national healthcare system funds. One review of 44,000 death certificates revealed that in low-income communities, common causes of death included cirrhosis of the liver, childbirth complications, respiratory diseases and lung tumors. In more affluent areas, women had higher rates of breast cancer.

Survivors use signed death certificates to file life insurance claims, settle estates and seek death benefits. One is needed to obtain a burial or cremation permit, which is combined, in some locations, with a transportation permit.

ABUSES

In 1866, a scandal in New York City spurred the need to regulate death certificates. When the city’s independent Board of Health was formed, police investigating the office of the former city inspector found a supply of signed, unnumbered burial permits. The inspector had been selling them to murderers, who used them to “legally” bury their victims!

Sometimes, a death certificate is used to fake a person’s death for insurance fraud. This approach typically requires avoiding law enforcement officials and relatives of “the deceased.” In one mid-1990s scandal, official-looking fake death certificates could be purchased for anywhere from $500 to $1,000. American criminals have even used counterfeit death certificates from less developed countries.

Death certificates have also become a tool for identity theft. When a fake death certificate uses a living person’s name, officials may freeze that individual’s assets, cancel credit cards, revoke licenses and cause enormous difficulties.

Unfortunately, U.S. death certificates have a high rate of inaccuracy, which isn’t surprising since only about 12% of American physicians receive training in filling them out. Up to 29% of doctors make errors about the age of the deceased, cause of death and whether an autopsy was performed. Death certificates of minority group individuals are the most error-prone.

Which error is most common? It’s identifying the cause of death, which is different from the manner of death. Many physicians make the mistake of listing as the underlying cause the mechanism of death. “Cardiopulmonary arrest” is not meaningful as a cause of death; eventually, everyone’s heart and lungs stop. The mechanism is an alteration of physical state or biochemistry, and it does get tricky. For instance, “old age” and presbycardia (“old heart”) are considered valid causes of death. One cause of natural death is addiction, a disease. Chronic alcohol and substance abuse are considered natural manners of death. However, “acute intoxication” is regarded as an accident.

Sometimes, doctors misreport a  cause  in  order to protect a family’s reputation. They might list “pneumonia” for an AIDS death or “accidental” for a suicide. Even before the AIDS epidemic, socially undesirable causes of death were often misrepresented on death certificates. These include alcoholism, syphilis, homicide, suicide and alcoholic cirrhosis of the liver. This kind of misreporting is more common where autopsy reports become part of the public record. (Some states have eliminated cause of death from publicly recorded death certificates.)

DEATH CERTIFICATE DILEMMAS

Usually, the funeral director acquires the death certificate and other needed legal documents and itemizes their costs on the bill. If a body must be shipped to a non-English-speaking country, necessary translation costs may be added. According to one major-city medical examiner, Delta, the airline used most frequently for body transport, even awards frequent-flier miles for the passage.

Funeral directors fill in the required information on a death certificate, which includes method and site of body disposition, and sign the form. Then the physician responsible completes his or her sections of the certificate, such as immediate cause and manner of death, significant conditions, details about any injury and whether a medical examiner was notified. Death certificates then go to the local or state government office that issues a burial permit. The death certificate (or its information) is sent to the state’s bureau of vital statistics and on to the National Center for Health Statistics.

However, it’s sometimes difficult for funeral directors to obtain the needed physician signature. Modern facilities such as managed-care HMOs and multi-specialty clinics may make it difficult to identify and track down the right physician. And survivors can’t bury or cremate without the signature of either an MD or a medical examiner on a temporary death certificate. A physician can sign only if a death was natural. Medical examiners must sign for cases involving potential public health threats, police action or other unusual circumstances. They can list the cause as “pending” until tests determine what it was. Usually, disposition of remains need not wait for a final autopsy report, which can take weeks.

One key purpose of modern death certificates is to prevent cover-up for murder. This can be difficult because for a non-natural death, the certificate must be completed by a trained official who has significant flexibility in determining the need for a post- mortem exam. When a physician can’t sign a death certificate and give presumed cause, a forensic pathologist or medical examiner will do an autopsy if a case requires police investigation. Ultimately, the medical examiner’s opinion will be based on all available information: medical records, the treating physician’s report, circumstances of death, investigation at the death scene, any inspection by police or fire marshal and autopsy.

In homicide cases, the medical examiner need not identify proof of intent, but he or she does have   to determine whether suicide was the method of death. Identifying the circumstances of a case really can be as complicated as forensic crime shows on cable make it seem. A medical examiner might have to figure out if tobacco use contributed to a death; the case might have involved two homeless people fighting over a pack of cigarettes.

Deaths aboard ships are handled distinctively. In England, British captains register any crew member or passenger death in the ship’s log, recording information similar to requirements on a death certificate. When the ship arrives at a British port, the captain must report the death to harbor authorities, who then investigate the circumstances.

Occasionally, autopsy, pathology or forensic findings appear well after a death certificate has been completed. In many jurisdictions, if findings become available within three years of the death, the physician who signed the original certificate can complete an amended certificate.

Procedures were so much simpler just 500 years ago!

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