CERTIFICATE OF DEATH Form SO.roved ,
BIRTH No. STATE OF
Bud#eLBu,,,u WO.CU-R876,2 STATE FILE No. .
!. PLACE OF DEATH
I
b. CITY. TOWN. OR LOCATION C. LENGTH OF STAY INlbI C.CITY. TOWN. OR LOCATION :5 I
d.NAME oF (If no{ inhospifnf, LTWe80ett addrea8)
; d.STREETADDRESS
NOSPITAL OR INSTITUTION
~? C. IS PLACE OF DEATH INSIDE CITY LIMITS? C. IS RESIDENCE INSIDE CITY LIMITS? If. IS RESIDENCE ONA FARM?
YES❑ NO❑ I YESD mu I YEs o NO❑
3.NAME OF Fir*t M{ddIe Laat 4.DATE Mmth Dau Year
DECSASEO
(Tnpcorprinl) . D~ATH
5. SEX 6. CCILOR OR RACE 7 MARRIED ❑ NEVER MARRIED❑ s. DATE OF BIRTH 9 AGE (In UCO?8 IF UNDCRI Y~R [IF UNDER24 IWS, [ml birthday) “~m,*, Do”’ Mm,, M{”, Wl~WED ❑ ‘DIVORCED C
Ioa. uSU~L oCCUPATION(.Gioc.kind of work done Im.KIND DF BUSINESS OR INDUSTRY II. BIRTHPLACE (safe 0, fo,ci~n Counov)
dur:nv mo81 of work:ng I:Jc, coen :f rctzredl 12,CIIIZSN W WHAT CCUNTRY7
a
E- C
T g 13.. FATHER,s NAME
gm 14.MOTNER.S MAIDEN NAME
k ,.
z
~<
15.WAS DECEASED EvER IN U. S. ARMED FORCES? 16,SDCIAL SECURITY NO. 17. INFORWAWz $ 1E’-. Iw.m .tilwm, (1/ w., vi.. m, m &* of -k) Address
u
La: .
~ 18. CAUSE OF OEATSS [Enter od# one cawe Wr lins /or(4), (b). and (c).]
Y INTERVAL SCTWEEN
T PARTL DEATH WAS CAUSED BY, 0N3ET ANO DEATH
s l.MMEDIATE CAUSE (a)
E —————
z~In
<$ Conditima, if an9.
1
DUE TO (b)-which gane ria to
;$ (
..—
abo?c cauae a).
-c 8t+8na Ihc
under-~- Iytng Ceuae [alt. DUETO (c)
& g ~ PART Il. OTH=SIGNlnu~ @Dl~-!~NG TO~~mw RmWDTO~E~MIWL
M — CONDl~N GIVEN [N PhNT l(n) 19. WAS AUTOFSY
cc ~ ~ PERFORMED
“ ~
53 k YESD NOD
0 * 20a. ACCIDENT SUICIDE ‘.,HoMIcIK ~. 0E3CRIEE NOYNUURYWCURRED. (Entmndu,e ojinjur# in Parl Ior ParllIoJl[em 18.)
. u a
=- 8 •1 •1 •1
i-< ~ ~. ::~:R;F Hour Month, Dar, Year
g u a. m.
E p. m.
~ ~ ~. IN.SURYOCCURRED ‘20c. PuCEOFIWURY (c. g., rnordotihw, ~f, CITY. TDWN. OR LDCATION
1- COUNTY
~ ~~~AT ❑ NO~~~.E a farm, /acEorv, ;Oect, ofice bldg., etc.) STATE
z .“
g 21. Iattemdedtheda~ea*e~f,Om . to ‘e’ alive on
~ Death occurred at
‘nd]asts”w him
m on thedate st.tedabove; and to the beat of myknowledte, from :hecause# etated.
0 a. stawrunc (Depree or tifle) ~. ADDRESS 22c, DATE SIGNEO
‘z I
~ 23a. BURIAL. aEM4Ti0fi. ~ DATE &. NAME Of CEMETERY OR CREMATORY Z3d. LDCATION (City, twn. or coun!#)
REMOVAL(SpciJ#) (S&de)
G
; 24.FUNERAL ENRECTOR A
A“DDRESS =. DATE RECD. BY LDCAL REG. 26. R6GISTRAR.S SIGNATURE
xIL, I I
Survey Questionnaire for Hospitals
.PMS. 3699 .0.,,.S.,,”’,,, ha, Q..”.ss”,.. the 1“48”84”.1
(3-61) a, P“bl ished [“ ,,, Federal ,egl, ter “ay 2,, ,9,, Budget 8 . . . . . h.. 68-6102
APP.OV.I ExPi.=s: 12-31-62
DEPARTMEIIT OF HEALTH, EDUCATION, AND IIELFARE
publicHealth Service - KOVS Hashlngton 25, D.C.
HOSPITAL UTILIZATION IN THE’ LAST YEAR OF LIFE
N= of Bcemed File Nuuber
Aidrea8 of mcea~ed Date of Birth
Hospital’In whichxceasea was a Patient Approximaterate of IEstDi6cWge
PAST I - HOSPIW (TASS~ WS INSTI~ON
A. HOW q ttis waE the wrsm whose = aPw=s abO= ~6c~&a fiOm ~S hOePi~l s~ceJ.~ 1, 19a7
—nuuber of Bepmate dischargessticeJ~ 1,19@ (Plessecompletia sectionbelow for esch of these treesbeginningwith the ieceased’slast stiy in this hospital. If therewere more than four sewa~
dischargessinceJ~ 1,19@, pkase attsch sewate sheet. )
PEHtoDs m~ DIS~
OF SASE ON ON FINALDIAGNOSES omTIoNs
mm
~-mT Month— Mmth—
FEFUOD
mY ~Y Secmiary
Ye2r Year
meek If none
❑
~
WT Month— Mon~ ,.
ST Day m~ ~ecm~
PESIOD
Ye— Yea
Checkif none
❑
~w
mm Wth_ Mont~
DEmm .
m Day -Y SecOniary
Year Ye—
Sheckif none
❑
~--OD Montbb Mon~
BEmm
mT Day Dsy Seconiary
Year_ Ye—
Sheck if none
❑
=ti H
.
45
A. Accorwg to your recordsor to your @rsoml howle~e, was the deceaseda patientin sny otherho6pitslor medicslinstitutionsinceJ~ 1, 19@7
1.0 Yes 2.0 No
(If Yes: please ~st below each hospitaland mdical institutionin which the .iecemedwas”a patient sinceJ~ 1, 19@)
1.Nmlle of Inatitutiorl
StreetAd&ess City or Place
Colm* state
Approximate MBchmgeDate 2. N8me of ~stitntim
StreetAddress , cityorPlace
3. Naue of Institution
StreetAddress City or Plsce
county sate
Apprtite DischargeDaw 4. !fm of Instituticl.
StreetAddress Cityor Place
Cmmty Sta+
Amoxlmate Mscharge M*
****** ***
Signatureof ~rson completingthisform N- of this institution
Your positionin this institution
PHS-3699 (3-61 )b. ck
BACK
.,.,0,,,,
I
Survey Questionnaire for Informants
Pris:s;;o
CO”,,B.”,,AG,,, has been assured !,. l“dlvld”.1
.s pub, l,t,.d 1“ th. Federal ,esl,t.r “?,y ,0, ,,59
DEPARTMENT OF HEALTH, EDUCATIOII, AND WELFARE Public Health Seivice - IIOYS
Ilashlng ton 25, D.C.
HOSPITAL UTILIZATION IN THE LAST YEAR OF
Budget Buree~ No.
Approval Exp. r.s:
LIFE
68-6102 12-31-62
Plea3eanswerthefollowlng ~estions aboutthe personp3med above. If You do not knw the exact anzwera,SIYZ your beBt estimates. Feel free to ask the”assist=ce of otherswho w be able to help you b ane.weringthe questlonz.
PAST I - EOSPI~
-A. SinceJ~ 1, 19~, w the peased a patientin a hospitalor medic@J.Wtitution?
l.HYes 2.U No (If No,S~ to ~ II on the rewrse side) B. How q ttis w he dischargedfrom these hoqitals sinceJ~ 1, 19@?
—-.-number of times (Plez.secmplete a sectionbelw for each of these dischargesbe~ with Mt hospital stw. For exmple, if & died in a hospital,t~s disc~ge shouldbe entiredaz his last hospital8tiy.)
1.IAST HosPIl!AT,Sm
A. When w he disctiged from the hospital? B. what is the = md -ss of the hospital?
-w ~onth ~e2r N&
C. HOW many ni&t6 w he in the hospital? City or Pla2e
—umber of,nights county state
2. mT ti w HosPm Sw
A. When w he UscWged from the hospital? B. What is the - ~d 2ddresBof the hospitti?
.m ~nth ~e- Name
C. How m tightsw he in the hospitti? City or Pla2e
_n*r of nishts Couuty state
3. mm Sm BS20SE w
A. When was he +achwged from =e hospital? B. What is the n= znd 3.ddre6sof the hospita17
42y Month ~ezr Ne$ne
C. How w nightswas he In the hospital? City or Place
_n*r of nights county State
k.HOSPITALSTAY BE~~ ~T
A. When w he dlschzxgedfrom the hospital? B. What is the name md addreesof the hospital.?
-w Month Year N@me
C. How q nightswas he in the hospital? City or Place
_nmber of nitits Cmulti sta~
m FROm
>
47
.
FASTII - ~~lIICS OFT2E DE~ -OW
A. Where Md the dece86ed Prson Me?
I.n At hme
2 .D m a hospital N=
City or Place
county ,- State
3.D Otherplace (specify )
B. king 19~, what =s the total incm of the deceasedand those of his ftily livingwith him? (IUC1* inccmw fran all smces such as wages, sties, rents frm Trqrt.y, wnsims, help fim relatims, etc.)
1.0 under *,m 3.0 W,wo - $6,9w ‘ 2.I-J$2,CC0- $3,9B 4.D&,W or more
If the dece66edm under 16 years of ase, = h m III belcr.r.
C. What W he doti mostof the 12 months before deathz
1.0 Worw 3.0 some- e16e (%clfy )
2.0 P.etirea
D. Whst m the higheetgradethe decemed attendedfi school? (Circlethe highestgade )
None 12345678 1234 1234>
Elementary mti School College
PART m - -Wow AEom m -Ow Cwmm ms m
A. Wter Wlaw the m ma 6ddressof the pram actuallycmleting this form,even Ifdifferent tiom the prson to *m the form WS6 tiled.
n-street Address city
county stab
B. m p bou of fianeoneehe who misht be able to W to the informationthat YOU SUPPlied?
1.0 Yes 2.U No
If Yes: what is the n= and Wess of this prsm?
Nenle Address
***** **
Use the spscebelow to p.rti~ w &tionsl MormstAon about the &ce-ed Persontshospitslcsre.
PHS.37 00 (3-61 )b. ck
BACK
SeYzes 1.
SeVies 2.
Series 3.
SeYies 4.
bc}-ies 10.
SeVies 11.
SeVies 12.
Sevies 20.
SeVies 21.
Se)ies 22.
OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH
Public Health Service Publication No. 1000
PYog~ams and collection procedures. —Reports which describe the
STATISTICS
general programs of the National Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and other material necessary for understanding the data.
Reports number 1-4
Rata e~’aluation ad methods reseaych. —Studies of new statistic~l methodology including: experiment.~1 tests of new survey methods, studies of vital statistics collection methods, new analytic~l techniques, objective evaluations of reliability of collected data, contributions to statistical theory.
Reports number 1-18
Analytical studies. —Reports presenting analytical or interpretive studies based on vital and health sta-tistics, carrying the analysis further than the expository types of reports in tbe other series.
Reports number 1-4
Documents and committee vepovts.— Final reports of major committees concerned with vital and health statistics, and documents such as recommended model vital registration laws and revised birth and death certificates.
Reports number 1 and 2
Data Fvom the Health InteYuiew Suvvey .—Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other health-related topics, based on data collected in a continuing national household interview survey.
Reports number 1-29
Data Fvom the Health Exammation Suvvey.— Statistics based on the direct examination, testing, and measurement of national samples of the population, including the medically defined prevalence of spe-cific diseases, and distributions of the population with respect to various physical, physiological, and psychological measurements.
Reports number 1-16
Data From the Healtlz Recovds Sur~’ey. — Statistics from records of hospital discharges and statistics relating to the health characteristics of persons in institutions, and on hospital, medical, nursing, and personal care received, based on national samples of establishments providing these services and samples of the residents or patients.
Reports number 1-4
Data on movtaLity.-Various statistics on mortality other than as included in annual or monthly reports—
special analyses by cause of death, age, and other demographic variables, also geographic and time series analyses.
Reports number 1 and 2
Data on mtality, marviage, and divorce. —Various statistics on natality, marriage, and divorce other than as included in annual or monthly reports — special analyses by demographic variables, also geo-graphic and time series analyses, studies of fertility.
Reports number 1-9
Data Fvom the Natioml Natality ad Mortality Su~veys. - Statistics on characteristics of births and deaths not available from the vital records, based on sample surveys stemming from these records, including such topics as mortality by swiceconomic class, medical experience in the last year of life, characteristics of pregnancy, etc.
Reports number 1 and 2
I’or a list of titles of reports published in these series, write to: National Center for Health Statistics U.S. Public Health Service
Washington, L).C. 20201