Certificate of Death
These forms are a big deal. Just like an agenda, a doctor’s note to miss work, or a W2, they contain information that somebody, somewhere considers crucial. When I first filled them out, I was casual. I do that to make my life easier. But I quickly learned casual can lead to sloppy. And sloppy doesn’t cut it. It shouldn’t in an elected, official office. And death, the business of the coroner, is a door that has closed. It deserves one’s solemn attention. And the forms, while paper, are the record of one’s solemn service. So, I started trying to do better.
While we’re at it, let me tell you about sloppy. You need to understand that the vast majority of deaths in any jurisdiction are not “coroner deaths”. That is, they are certified by their attending physician. I certified deaths as a doctor, and also as a coroner. And I got to know the line between the two very clearly. Sometimes I used it to my advantage. I considered that I was using it to the taxpayers advantage, but I’ll let you be the judge of that.
Let’s say I get a call from a sheriff’s patrolman out in the county. He tells me he’s in an old lady’s home and her kids had called because she wasn’t picking up. So they knocked, she didn’t answer, and they found her dead in her bed. She’s old. Like 90. But living on her own, doing her dishes, and they call me as the coroner to see if I want to go investigate. I ask if there’s any signs of struggle, break-in and they say no. I tell them to go to her medicine chest. Read me her pill bottles. I recognize the meds, nothing worrisome, no narcotics or benzos. “Who is the prescribing doc?” I ask.
They give me the name. I call the doc. They talk to me. “Mrs. Dead has died peacefully. Can you certify her cause of death?”
“Well, she did have high blood pressure, and I was thinking she needed an EKG.”
“When did you last see her?”
Pause. “It looks like it was about two months ago. Though she really wasn’t complaining of anything new.”
“So you can certify her death?”
And her is where the rubber meets the road. Do they want to make their best guess, or do they want me, the coroner, to make my best guess? Most primary care doctors agreed to certify the cause of death. And so, I had to do less work.
But here’s the sloppy, scary side of that scenario. My sister died too young of breast cancer. Her widower needed her death certificate for insurance and legal reasons. When he got it, the cause of death was listed as “lung cancer” and due to her smoking. My former brother in law went ballistic, as he should have. “She never smoked a cigarette in her life!” It turned out, my sister’s oncologist was out on vacation and his partner had filled out the form and read the details from the wrong chart. So this vital form, with vital statistics, is completed by us fallible humans, doctors, coroners, idiots.
I was impressed with the significance of these forms when I stopped by the Idaho Department of Vital Statistics in our state capital. I was now an elected State Senator. I was no longer a county coroner, though they still knew me from our many polite and instructive phone conversations. On a slow afternoon in our capital, I stopped by the Vital Statistics Office. I asked for a blank form, to help me with these stories. They frowned. I smiled and casually explained my need. The receptionist went back to the business area and a more official lady came forward. She explained they didn’t usually “give out” blank forms. Each was numbered and catalogued. My request was unusual. They would have to catalogue a voided form. But she smiled, remembering my many and painful conversations with their office and handed me a blank form. Back in those days we still lived in a small state where somebody 300 miles away struck a bell.
Let us examine this form.
I draw your attention to the numbered fields, 1-45. I rarely dealt with 1-18, though #18 says: “Was the coroner contacted…?” More on this later. These first fields were usually filled out by the funeral home in nice, typed font. Who has a typewriter these days?
These fields connect the decedent to their birth. Genealogy freaks love these fields. Mother’s maiden name, birthplace and all build the family trees. But I didn’t pay much attention up here.
Fields 19-22 have to do with the place and time of death. Usually these were filled out too. Only rarely did I get to assert my authority in this section.
There was a time once.
A young man, beloved and well known in our community disappeared. It was back when being gay was just coming out. But he was openly. And then he was gone. I was not involved at all in the investigations around his disappearance. But after a couple years, the prosecutor asked me to file a death certificate. I refused. “Show me a body.”
Then about five years later they came to me with a jawbone, found in the eastern, wild and remote county. A forensic dentist had confirmed the identity.
So, I filed a death certificate. I could not imagine a person escaping a town, a relationship, debts, or harassment and then rebuilding their life without their jawbone. I had to address lots of blank fields.
#14 Method of Disposition: OTHER
#21 City Town or Location of Death: UNKNOWN
#23 Date of Death: UNKNOWN
And then I had to put all the unknowns down in the fields I was familiar with.
#27 is the big one: Cause of Death.
I like the way this cell is structured. The top line is the IMMEDIATE cause of death. Say a guy dies in a nursing home after his stroke, probably from pneumonia. So that’s the top, “pneumonia”.
But then they let you say “due to or as a consequence of”…
So, let’s say he had a stroke and he aspirated. So, on the second line you can say “aspiration”, then on the third line, “stroke”.
Or, if you want to save ink, you could have written on the first line “aspiration pneumonia” and then the second line “stroke”. In any event, you are letting the record keepers know you are aware of the sequence and letting them know too.
I had a guy who died like this in a nursing home. I called it aspiration pneumonia, due to his paralysis from a car wreck. That one got me a call from the capital.
“Dr. Hawthorne, you have listed the deceased as dying from pneumonia due to a car accident.”
“Yes”
“But you have stated his manner of death was natural.”
Cell # 31 is crucial: Manner of death. There are only six choices. No room for creativity, just six choices and you gotta check one box. And the box you check needs to make sense in #27 “cause of death”. I hadn’t known just how related these two issues were.
“A car accident causing this man’s death is not natural.”
She was right. But I countered. “Paralyzed people aspirate all the time and get pneumonia. Isn’t that a natural occurrence?”
She was patient and kind, teaching me on the phone. “The original cause or occurrence defines the manner of death. Since this man was paralyzed from a car accident, his manner of death would be accidental, not natural.”
I considered her logic. “But if he was paralyzed from a stroke, then it would be natural?”
“Yes”
I got a lot of calls from our state capital early on.
So, let’s look at the six “Manner of Death” choices:
Natural
Accident
Suicide
Homicide
Pending Investigation
Could not be Determined
I was always bothered there wasn’t one to check for “Stupidity” or “Stubbornness” or “Weakness”. Maybe these all fit into “Natural”.
But if the dead guy was addicted to narcotics and overdosed, was it an accident? Or did he want to die, then it would be suicide? That was my job. Figuring our why these people died.
I once got crosswise with a local judge when testifying about a death. I had checked the Manner of Death box “Homicide”. The prosecutor was entering the death certificate as evidence, and I was on the witness stand. The judge glanced at the form before allowing it to be admitted. “You can’t make that conclusion!” he glared at me. “That is for this court to decide.” I looked at him and shrugged. Checking that box was my job.
The many years of death investigations and checking boxes made me think of the stories of these deaths. Stories aren’t spreadsheets. The stories are true. And they burdened me.