PHYSICIAN'S MANUAL ON MEDICAL CERTIFICATION OF CAUSE OF DEATH

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Title
PHYSICIAN'S MANUAL ON MEDICAL CERTIFICATION OF CAUSE OF DEATH
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PHYSICIANS' MANUAL
ON MEDICAL CERTIFICATION
OF CAUSE OF DEATH

VITAL STATISTICS DIVISION
OFFICE OF THE REGISTRAR GENERAL , INDIA
MINISTRY OF HOME AFFAIRS
NEW DELHI
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PHYSICIANS’ MANUAL
ON MEDICAL CERTIFICATION
OF CAUSE OF DEATH
(Second Edition)

VITAL STATISTICS DIVISION
OFFICE OF THE REGISTRAR GENERAL, INDIA
MINISTRY OF HOME AFFAIRS
NEW DELHI

CONTENTS

Page No.
Preface to the second Edition
Preface to the First Edition
1.

2.

3.

4.

v

vii

INTRODUCTION

1

1.1 Legal provisions
1.2 Cause of death
1.3 Form of medical certificate
1.4 Physicians’responsibility

1
2
3
4

SPECIFIC INSTRUCTIONS

6

2,1
2.2
2.3
2.4
2.5
2.6
2.7
2.8

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6
6
6
6
9
9
8

Name of deceased
Age
Date of birth
Marital status
Method of certification of cause of death
Accidents
Female death
Ensuring completeness of information

EXAMPLES OF CERTIFICATION

12

3.1 Simple situations
3.2 Complicated situations
3.3 Incorrect and correct filling of form
3.4 Importance of reporting sequence accurately

12
13
16
19

ANNEXURES

Examples of incomplete descriptions of cause of death 21
Form No. 8 and 8A
26

iii

PREFACE TO THE SECOND EDITION
Even before a year is complete, there has been
overwhelming response for bulk supply of the manual
from almost every State. The manual has thus been
found to be timely for use by Physicians and Medical
Officers of Government hospitals and those attached to
medical colleges, where the scheme of medical certifica­
tion of cause of death is being implemented, to star
with. The bulk demand has come from States which
have already entered the phase of the scheme, covering
specialised hospitals, district and sub-divisional
hospitals and primary health centres. Hence this second
edition.

The manual has been, in this edition, provided
with a new sub-section under the heading “Incorrect
filling and correct filling of the medical part of the
certificate” in section 3 on “examples of certification”.
The examples have been provided by Shri T.D. Dhamija,
Officer incharge, Medical Record Unit, Safdarjung
Hospital, New Delhi, based on case-histories of the
hospital to whom our thanks are due. The edition, we
hope, would contribute to the improvement in the
working of the scheme of medical certification of cause
of death.
V.S. Verma
Registrar General, India

NEW DELHI

25th April, 1984

(v)

PREFACE TO THE FIRST EDITION

The importance of statistics on cause of death is well
recognised and these data are in demand by health planners,
administrators and medical professionals. The scheme on medical
certification of cause of death formulated by the office of the
Registrar General, India is a big step forward towards establish­
ment of a system in the country for data on cause of death. The
scheme envisages the gradual introduction of medical certification
of cause of death in a phased manner and, to begin with, in medical
and teaching hospitals where operational procedures for recording
the vital events are streamlined to some extent. In the second phase,
the scheme would be extended to specialised hospitals, district and
sub-divisional hospitals and primary health centres would be
covered. Finally, the scheme is expected to cover private physicians
also, so that formal enforcement of the Registration of Births and
Deaths Act, 1969 would be facilitated.
The scheme on medical certification of cause of death has been
functioning in different phases in different states Its success largely
depends upon the active involvement and cooperation of the physi­
cians and for this purpose, it is felt that they should have the benefit
of a manual on medical certification. This manual is designed
to serve this purpose. It defines the physicians’ responsibilities and
provides detailed instructions for completion of the medical
certificates on cause of death.
The initial draft of this manual was widely circulated among
the State Medical and Health Directorates and was discussed in a
number of training camps The publications of the W.H.O. on the
subject were extensively used in finalising the manual and the benefit
derived from these publications is gladly acknowledged. Further,
the cooperation received from Chief Registrars of Births and Deaths
of States and Union Territories and Directorate General of Health
Services, New Delhi in finalising this manual is gratefully acknow­
ledged. In particular my thanks are due to Dr. H.N. Ranganathan,
Deputy Director, Directorate of Health Services Pune, and Shri
T.D. Dhamija, Officer incharge, Medical Record Unit, Safdarjung
Hospital for providing us some examples of case histories for inclusion
in this manual. I must also thank the Vital Statistics Division of this
office which has done commendable work in compiling this manual.

(vii)

In particular I am happy to record appreciation of the efforts
put in by Dr. M. Holla, Joint Registrar General, India and his
colleagues Shri K.N. Shrinivasan, Assistant Registrar General,
Shri K.S. Krishnan, Senior Research Officer, Shri M.K. Ahuja,
Dy. Director of Census Operations and Shri J.S. Rastogi,
Assistant Director of Census Operations in bringing out this
manual.
Our task would have been more than fulfilled if this manual
contributes towards the successful implementation of the scheme
on medical certification of cause of death in the country.

P. Padmanabha
Registrar General, India

NEW DELHI

13 January, 1983

(viii)

1
INTRODUCTION

Mortality statistics form an integral part of the vital statistics
system. They are one of the basic components of population
growth. Further, the cause specific mortality rates are key
indicators of the health trends in the population and are provided
on scientific basis by the system of medical certification of cause
of death.

The data on cause of death contained in the certificate serve
many purposes : they help in assessing the effectiveness of public
health programmes and provide a feed-back for future policy and
implementation. They are essential for better health planning and
management and for deciding priorities of health and medical
research programmes.

1.1

Legal provisions

It is because of this importance that a provision has been
made in the Registration of Births and Deaths Act (RBD), 1969
for certification by a medical practitioner who has attended the
deceased during the latter’s last illness. There is also an enabling
provision in the Act which empowers the State Government to
introduce the system of medical certification of cause of death in
specified areas taking into consideration the facilities available and
other related factors. The relevant sections of the Act are :

Section 10 (2)
In any area, the State Government having regard to the
facilities available therein in this behalf, may require that a
certificate as to the cause of death shall be obtained by the
Registrar from such person and in such form as may be
prescribed.

Section 10 (3)
Where the State Government has required under sub-section
(2) that a certificate as to the cause of death shall be obtained, in
the event of the death of any person who, during his last illness was
attended by a medical practitioner, the medical practitioner shall,
after the death of that person, forthwith, issue without charging any

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fee, to the person required under this Act to give information
concerning the death, a certificate in the prescribed form stating to
the best of his knowledge and belief the cause of death ; and the
certificate shall be received and delivered by such person to the
Registrar at the time of giving information concerninglthe death as']
required by this Act.
The rules framed by the State Governments on the subject
further describe the procedure involved in the final disposal of the
certificates as :
The certificate as to the cause of death required under sub­
section (3) of section 10 shall be issued in Form No. 8/8A and the
Registrar shall, after making necessary entries in the register of
births and deaths, forward all such certificates to the Chief Registrar
or the officer specified by him in this behalf by the 10th of the
month immediately following the month to which the certificates
relate.
The Act also incorporates a clause on confidentiality of the
information on cause of death available on the registration records.
The relevant section of the Act reads as under : —

Section 17 (1) (b)
Subject to any rules made in this behalf by the State Govern­
ment, including rules relating to the payment of fees and postal
charges, any person may obtain an extract from such register
relating to any birth or death:
Provided that no extract relating to any death, issued to any
person, shall disclose the particulars regarding the cause of death
as entered in the register.

1.2

Cause of death

A cause of death is a disease, abnormality, injury or poisoning
that contributed directly or indirectly to death. A death often
results from the combined effect of two or more conditions. These
conditions may be completely unrelated, arising independently of
each other ; or they may be causally related to each other, that is,
one condition may lead to another, which in turn leads to a third
condition and so on. Where there is a sequence, the underlying cause,
i.e., the disease or injury which initiated the sequence of events will
get selected for the purpose of tabulation.

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The underlying cause of death is :
(a) the disease or injury which initiated the train of events
leading directly to death ;
or
(b) the circumstances of the accident or violence which
produced the fatal injury.

All these morbid conditions or injuries consequent to the
underlying cause relating to death are termed as antecedent and
immediate causes.
Form of medical certificate
The standard format of the certificate is incorporated in the
rules made by the State Government. The format of the certificate
proper (medical part) conforms to the standard prescribed by
the World Health Organisation (WHO) and has the following
features :
1.3

CAUSE OF DEATH

Interval between
onset & death approx.

I.
Immediate cause-.
State the disease, injury or (a)
complication which caused
due to (or as
death, not the mode of dying
a consequence
such as heart failure, asthenia,
of)
etc.

Antecedent cause:
Morbid conditions, if any,
giving rise to the above
cause, stating the underlying
conditions last.

(b)

(c)
H.
Other significant conditions
contributing to the death, but
not related to the diseases or
condition causing it.

due to (or as
a consequence
of)

..............

4

Besides the medical part, the form also includes some minimum
demographic and identification particulars about the deceased. The
forms have a detachable portion separated by perforation mark
containing information on fact of death. Separate fotms have been
provided for hospitai and non-hospital events which are given in the
annexures.
1.4

Physicians’ responsibility

The physicians’ primary responsibility is to complete the
medical part of the certificate regarding all diseases, morbid
conditions or injuries which either resulted in or contributed to
death. Causes of death are classified, coded and grouped according
to the current revision (IX at the moment) of the International
Classification of Diseases (ICD) recommended by WHO. When
deaths result from a single condition, such as an acute infectious
disease, certification and classification present no difficulty. How­
ever, this is not the case always and the problem arises of which
one of multiple causes to select as the cause ot death. Some of
them may be causally related to each other in a sequence. If unti­
mely deaths are to be prevented the chain of events has to be cut,
or cure instituted at some intermediate point. The most effective
public health objective is to prevent the precipitating cause from
operating and hence the relevance of the underlying cause. Res­
ponsibility is placed on the certifying physician for indicating
specifically all the several conditions and the chain of events if
a sequence can be identified. The certifier (Physician) should
record the diseases'conditions in an order leading back to the
underlying cause if a sequence can be found and put any other
conditions contributing to death separately if not directly forming
part of the fatal sequence. The medical part of the certificate
should normally be the responsibility of the attending physician
and based on his individual assessment. In cases of violent deaths
and other medico-legal cases usually brought to the notice of a
medical examiner at the post-mortem stage, the certificate may
be filled by the medical examiner on the basis of evidence noticed
by him. The fact of death in such cases should, however, be
communicated to the local registrar in the prescribed format
pending the final filling up and transmission of the medical
certificate to the registrar concerned. The information on cause
of death is kept confidential and is not indicated on death certi­
ficate that may later be issued by the Registrar of Births and
Deaths. This safeguard is intended to enable the doctors to
bestow sufficient care and attention in writing the certificate so
that mortality statistics will reflect the best medical opinion,
concerning causes of death.

5
The various particulars, other than those of the medical part
on cause of death, are also required for reporting the death by
the hospital to the registration authority in the prescribed format.
The certifier will ensure that all the necessary particulars are given,
besides his own statement regarding the chain of events pinpointing
the underlying cause of death and then sign the certificate. The
detachable portion of the form containing only the fact of death
without disclosing the cause of death may either be signed by the
certifier or the medical officer of the hospital and handed over to
the relatives of the deceased. The form of medical certificate of
cause of death is to be sent to the local Registrar of Births and
Deaths alongwith the death report in the prescribed format within
the prescribed time limit.

2
SPECIFIC INSTRUCTIONS
2.1

Name of deceased

To be given in full. Do not use initials. Also give name of
father (or husband in case of married female) after the name
of the deceased, using appellation s/o or d/o or w/o. In case of
infants not yet named, write son (or daughter) of, followed by
names of mother and father.
2.2

Age

If more than a year old, give age in years last birthday (com­
pleted number of years). If under one year, give age in months and
days. If under 24 hours, give in hours and minutes.

2.3

Date of birth

This may be given, if possible. However, age of the deceased
should be stated whether exact date of birth is known or not. Date
of birth is important particularly in case of infants.

2.4

Marital status

State whether Single (S), Married (M), Widowed (W)
Divorced (D).
2.5

or

Method of certification of cause of death

2.5.1 The medical part of the certificate is designed by the
WHO to facilitate reporting the underlying cause of death and
to obtain information on the causal and pathological sequence of
events leading to death. It consists of two parts, the first relating
to the sequence of events leading to death, and the second to other
significant conditions that contributed to the death.

2.5 2 This part should be written by the attending physician
or a physician having personal knowledge of the case history.
The names of the disease-, should be written in full and legibly
to avoid the risk of their being misread. Abbreviations and short
form of disease condition may not he used. He should avoid

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indefinite or inadequate terms. Inadequate descriptions may put
the statistical office in difficulty at the time of classification of the
data. Mention of treminal events or mode of dying as the only
entry in the statement leaves the certificate incomplete. Simillary,
symptomatic remarks will not suffice. A properly completed
certificate will show the underlying cause on the lowest used line of
part I and the conditions if any, as a consequence thereof will have
been entered above it in ascending causal order of sequence.
2.5.3

Part I of the cause of death statement

Only one cause is to be entered on each line of Part I. The
underlying cause of death should be entered on the lowest line used
in this part. The underlying cause of death is the condition that
started the sequence of events between normal health and the
(direct) immediate cause of death.

Line (a) : Immediate cause

The direct or immediate cause of death is reported on line (a).
This is the disease, injury or complication that directly preceded
death. It can be the sole entry in the statement if only one condition
was present at death. There must always be an entry on line (a).

The mode of dying (e.g., heart failure, respiratory failure)
should not be stated at all since it is no more than a symptom of the
fact that death occurred and provides no useful information.
In the case of a violent death, enter the result of the external
cause (e.g., fracture of vault of skull, crushed chest).

Line (h) : Due to

(or as a consequence of)

If the condition on line (a) was the consequence of another
condition, record that in line (b). This condition must be antecedent
to the immediate cause of death, both with respect to time and
etilogical or pathological relationship. In case of injury, the form of
external violence or circumstances of accident is antecedent to an
injury entered on line (a) and should be entered on line (b),
although the two events are almost simultaneous (e.g., automobile
accident, fall from tree).
An antecedent condition might have just prepared the way for
the immediate cause of death, by damage to tissues or impairment
of function, even after a long interval.

8

Line (c):
The condition, if any which gave rise to the antecedent
condition on line (b) is to be reported here. The remarks given for
line (b) apply here also. If the condition on line (b) is the
underliyng cause, nothing more be entered on this line. However, if
the sequence of events comprise more than three stages, extra line
(and entries) may be made in Part I.
However many conditions are involved, write the full sequence,
one condition per line, with the most recent condition (immediate
cause) at the top, and the earliest (the condition that started the
sequence of events between normal health and death) last.

Normally the condition or circumstance on the lowest line
used in Part I will be taken as the basis for underlying cause
statistics, though classification of it may be modified to take
account of complications or other conditions entered by special
provisions of the ICD.
2.5.4

Part IJ: Other significant conditions

Enter, in order of significance, all other diseases or conditions
believed to have unfavourably influenced the course of the morbid
process and thus contributed to the total outcome but which were
not related to the disease or condition directly causing death.
There will be cases where it will be difficult to decide whether
a condition relevant to death should be recorded as part of the fatal
sequence in Part I or as a contributory condition in Part II.
Conditions in Part I should represent a distinct sequence so that
each condition may be regarded as being the consequence of the
condition entered immediately below it. Where a condition does
not seem to fit into such a sequence, consider whether it belongs
in Part II.
2.5.5

Interval between onset and death

Space is provided, against each condition recorded on the
certificate, for the interval between the presumed onset of morbid
condition and the date of death. Exact period should be written
when it is known; in other cases approximate periods like “from
birth”, “several years” or “unknown” should be indicated. This
provides a useful check on the sequence of causes as well as useful
information about the duration of illness in certain diseases.

9
2.6

Accidents

If suicide or homicide is ruled out, how the fatal injury
occurred should be explained indicating briefly the circumstances
or cause of the accident. In case of medico-legal cases, the certi­
ficate has to be given by the police authorities. However, the
Registrar should be informed of such cases, by the hospital.
2.7

Female death

Information on pregnancy and delivery is needed in case of
death of women in the child-bearing age (15 to 49 years) even
though the pregnancy may have had nothing to do with the
death.

2.8

Ensuring completeness of information

2-8.1 While giving the causal chain of events in the statement
of cause of death, a complete case history is not required but, if
information is available, enough details may be given to enable
proper classification of the underlying cause. The certifier cannot
always be certain as to what details are required and therefore,
a list giving examples of incomplete descriptions and what addi­
tional information are required is included in the annexure for
guidance. The terms included in the annexure are those employed
usually and are of the following types :—
A symptom that may arise from different group of
diseases.
(ii) A morbid condition that could result from several types
of infection, known or unknown.
(iii) With connotation of any of several morbid conditions
having distinctive categories in the classification list like
acute, sub-acute, chronic, simple, etc.
(iv) Mention of a disease which is generally localised,
without indicating the organ or part of the body
affected.
(v) A morbid condition that requires for its classification,
a knowledge of the circumstances in which it arose.

(i)

2.8.2 As a general rule, record diagnoses as precisely as the
information permits, incorporating relevant details from histological
or autopsy reports. Where an important detail is unknown the fact
should be stated.

10

2.8.3 The following gives the pertinent details required to be
spelt out in the medical part of the certificate corresponding to the
major cause group of mortality.
1. Infections : Acute, sub-acute or chronic, name of the disease
and/or infecting organism; the site, if localised; mode of trans­
mission, where relevant.
2. Neoplasms ; The morphological type if known; malignant,
benign etc., site of orgin of primary growth, and sites of secondary
growths.
3. Endocrine disorders : Nature of disease process or distur­
bance of function : For thyroid diseases, whether toxic; for dia­
betes, nature of complication or manifestation in particular site.

4.

Nutritional disorders ; Type of deficiency, etc., and severity.

5. Blood disorders : Nature of disease process; type and
nature of any deficiency for anaemias; whether hereditary (where
relevant).
6. Nervous system disorders : Disease process; infecting
organism (where relevant), whether hereditary (where relevant).

7. Circulatory diseases : Nature of disease process, site, if
localised; acute or chronic where relevant; specify rheumatic or
other etiology for valvular heart conditions; any complications.
8. Respiratory diseases : Nature of disease process; acute or
chronic; infecting organism, any external cause.
9. Digestive diseases : Nature of diseas e process; site of ulcers,
hernias, diverticula, etc. acute or chronic where relevant, nature
of any complication for ulcers, appendicitis, hernias.

10. Genitourinary disorders : Acute or chronic, clinical
syndrome and pathological lesions; site of calculi, infecting
organism and site of infections; nature of complications.
11. Maternal deaths : Nature of complication; whether ob­
struction occurred during labour; timing of death in relation to
delivery; for abortions, whether spontaneous or induced, legal or
illegal, if induced.
12. Musculoskeletal disorders : Nature of disease process,
infecting organism, underlying systemic diseases (where relevant);
site; complication, whether congenital or acquired for deformities.

ii
13.

Congenital anomalies : Site and type, complications.

14. Perinatal deaths : Condition in foetus or infant; conditions
in mother or of placenta, cord or membranes, if believed to have
affected the foetus or infant; for deaths associated with immaturity,
state length of gestation and/or birth weight; type of birth trauma;
and complications, etc.

15.

Injuries : Type, site, complications.

16. Poisoning : Substance involved; whether
suicide or homicide is ruled out).

accidental (if

17. Adverse effects of drugs in therapeutic use : State this fact
and name or drug, nature of adverse effect, complications; condition
treated.

18. External cause of accidents : For transport accidents, state
vehicle involved; whether deceased was driver, passenger, etc.
description of accident, place of occurrence; for other accidents,
specify circumstances and place of occurrence.
19. Old age or senility : This should not be given if a more
specific cause is known. If old age was a contributory factor it
should be entered in Part II only.

3
EXAMPLES OF CERTIFICATION

Some examples of situations drawn mainly from Indian
experience utilising case histories provided by the Safdarjung
Hospital, New Delhi and the Directorate of Health Services, Pune
are categorised into simple and complicated situations and explained
below.

3.1 Simple situations
3.1.1
I. (a) Peritonitis
(b) Perforation of Duodenum
(c) Duodenal ulcer
II. Carcinoma of bronchus

3.1.2
1. (a) Abscess of hand
(b) Incision of hand
(c) Tetanus
II.
3.1.3
I. (a) Toxaemia
(b) Severe anaemia of pregnancy
(c) ....................... •............ . ..........
II. Tuberculosis

3.1.4
I. (a) Asphyxia
(b) Drowning
(c)
II
12

2 days
3 days
6 months

10 days

13
3.1.5
I. (a) Fracture of vault of skull
(b) Collision between car he was driving and
heavy truck on road
(c)
II
3.1.6
I. (a) Uraemia
(b) Chronic nephritis

15 min

3.2C oniplicated situations

As an aid to write the statement properly, some cases from
hospital records arh abstracted here to indicate typieal problems.

3.2.1 Case History
On 3-1-1977, a 60 year old female was admitted with a
“'Strangulated Femoral Hernia” which had started 4 day earlier.
She came complaining of abdominal pain and fecal vomits.
Apparently, the small intestines were perforated even before. On
4th January, she underwent a release of hernia and the recession
of the Intestines, with an end to end "Anastomosis’’. On 5th
January, she started developing signs of ‘‘Peritonitis’, and following
that died on 14-1-1977.
Statement
I. (a) Peritonitis, acute
(b) Perforation of small intestines
(c) Strangulated Femoral Hernia.
II
............

12 days
15 days

Explanation : Clearly, acute peritonitis led directly to death
and therefore appears on line (a). Performation of small intestines
gave rise to the immediate cause shown in line (a) and therefore
appears next in line (b). Strangulated Femoral Hernia was the
cause of intestinal perforation anq was the cause which initiated
the chain of events leading to death and this is the underlying
cause which is written on line (c).

14

3.2.2. Case History
On 14-1-1976 and old man slipped on same level and fell
down, resulting in fractures. After being admitted for care, froctures
of the left Ischium and Ilium were reduced. The patient then
suffered from Azotemia, genral arteriosclerosis, artericlctic heart
disease and pulmonary emphysema. He developed “Bronchopneu­
monia” on 15th February and died 6 days later. Autopsy rcuealed
also fractured hip and pelvis, cardiac hypertophy. chronic fibrous
myocarditis and coronary sclerosis.
Statement

(a) Bronchopnemonia
6 days
(b) Fracture of left Ischium & Ilium
7 day
(c)
II.
Arterioslerotic heart with coronary sclerosis,
I.

Explanation : Bronchopneumonia is ccrtinly the immediate
cause of death. The fracture of left Ischium and Ilium gave
Arteriosclerotic Heart Disease with coronary Sclerosis were, no
doubt, significant conditions contributing to death and are there­
fore given in Part II.

3.2.3

Case History

On 25-8-1964 a 53 year old male was admitted in hospital.
X-ray showed. “Adenocarcinoma of the rectum” but no evidence
Syphiiis was also noticed and treated. He was discharged from
nospital in November 1964, as improved.

On 3-3-1966, he got X-rayed which showed pelvis apparently
normal; however, there was an unusual shadow to the left of the
sacrum. On 19-6-1966, he was re-admitted with recurrenr carci­
noma of the rectum with invasion of the urinary bladder. He was
discharged, unimproved on 27-7-1966.
On 4-1-1967 he was again admitted for the same ailment.
Examination showed recurrent carcinoma of the rectum wtih
invasion of the urinary bladder and “Metastasis” througout the
abdomen, syphilis and decubitus ulcers. Bronchopneumonia
developed on 9-1-1967 and the patient died 3 days later.

15
Statement
I. (a) Bronchopneumonia
3 days
(b) Metastatic cancer of bladder and abdomen
(c) Aden carcinoma of rectum
II. Syphilis

Explanation : Since the metastatic lesions were the result of
the Adeno carcinoma of the rectum, the primary site is recorded as
the underlying cause of death.
3.2.4 Case History
On February 1st, a 58 year old men presented at a clinic
complaining of long duration *hemoptisis “ and loss of weight. On
examination he was found actually anaemic and therefore admitted
in hospital. The diagnosis was advanced pulmonary TB, reacti­
vation type with cavitation, perhaps of 8 year duration. The patient
also suffered from generalised arterioscelerosis, probably of long
duration. He also had moderate varicose veins of the lower extermity.
On admission, the patient had acute and massive pulmonary haemorr­
hage he died that eveniug.
Statement
I. (a) Pulmonary haemorrhage
10 hours
(b) Advanced pulmonary TB
8 years
(c)
II.
Generalised arterioscelerosis and varicose
veins of lower extremity.

Case History
A man of 63 years had been treated for seme years for malig­
nant hypertension and developed hypertensive heart disease and
chronic renal failure While seriously ill with the heart condition,,
he developed acute appendicitis, and the appendix ruptured, Appen­
dicectomy was carried out successfully but the heart condition
deteriorated further and he died 2 weeks later.
3.2.5

Statement
I. (a) Congestive heart failure
(b) Cardiac hypertrophy
(c) Malignant hypertension

2 weeks
some years

18

Illustration :
In this example, the Medical Officer should have maintained
the train of events in Part-I and other significant conditions in
Part-II, as mentioned in the correct certificate.
4. Part-I

Part-II

Incorrect Certificate
(a) Nephrectomy
(b) Edema Face, Foot

(c) .............................
Embryoma of Kidney

Correct Certificate
(a) Edema Face, Foot
(b) Embroyoma of
K idney
(c) .............................

Illustration :
The Medical Officer has recorded operative procedure
“Nephrectomy” in Part-I and other condition “Edema Face and
Foot” which is due to the disease “Embryoma of Kidney” stated in
Part-II, should have been written according to the sequence and
operative procedure should have been recorded in the column made
for “Operation performed”.

5. Part-I

Incorrect Certificate
(a) Polycystic Kidney
(b) Renal Failure and
Hypertension
(c) Ischaemic Heart D

Part-II

Correct Certificate
(a) Renal Failure
(b) Hypertension
(c) Polycystic Kidney
Ischaemic Heart
Disease

Illustration :
The certificate should have been got completed by the
Medical Officer as mentioned in the correct certificate because
Renal Failure, Antecedent direct cause and terminated by the con­
dition mentioned at (c) of Part-I as the underlying cause of death
and unrelated cause “Ischaemic Heart Disease” in Part-II.
6.

Part-I

Incorrect Certificate
(a) Intestinal Obstruction

(b) Femoral Hernia
(c) ..........................
Part-II

Correct Certificate
(a) Femoral Hernia
with obstruction
(b) ..........................
(c) ..........................

19

Illustration :
In this example all the conditions recorded by the Medical
Officer are co-related but it should have been mentioned as in the
correct certificate because ICD provides a combined code for
these conditions.
Keeping in view the above mentioned examples with their
illustrations, all the Medical Officers are requested mainly to know
the contents, as under, Part-I and Part-II of International Form of
Medical Certificate of Cause of Death.
“In Part-I is reported cause leading directly to death at line
(a) and also the antecedent conditions at line (b) and (c) which gave
rise to the cause reported in line (a), the underlying cause being
stated last in the sequence of events. However, no entry is neces­
sary in lines (b) and (c) if the disease or condition directly leading
to death, stated in line (a), describes completely the train of
events.”

“In Part-II is entered any other significant condition
which unfavourably influenced the course of the morbid process
and thus contributed to the fatal outcome, but which was not
related to the disease or condition directly causing death.’’
3.4 Importance of reporting sequence accurately

The following illustrates the importance of accurately stating
the sequence of morbid conditions in order to allow selection of the
cause considered “underlying” by the attending physician

A diabetic man who had been under insulin control for many
years developed ischaemic heart disease and died suddenly from a
myocardial infarction. Most people consider there to be a
relationship between diabetes and ischaemic heart disease but its
nature is not yet fully understood. Depending on the role, the
doctor consider to have been played in the fatal outcome by one or
the other conditions, the following certifications are possible.
1. If the doctor considered that the heart condition resulted
from the long-standing diabetes, the sequence would be :—
t-.

(a) Myocardial infarction
1 hour
(b) Chronic ischaemic heart disease
5 years
(c) Diabetes mellitus
12 years
and the statistical office would select diabetes as the underlying
cause of death.
I.

20
2. If the doctor considered that the heart condition developed
independently of the diabetes, the certification would be : —
I. (a) Myocardial infarction
1 hour
(b) Chronic ischaemic heart disease 5 years
II. Diabetes mellitus
12 years
and the heart condition would be recorded as the
cause.

underlying

3. If the man had instead died from some other complication
of the diabetes, such as nephropathy, the heart condition playing
only a subsidiary part in the death and the doctor being uncertain
that it arose from the diabetes at all the certificate should be in
the form :—
I. (a) Acute renal failure
(bj Nephropathy
(c) Diabetes mellitus
II.
Chronic ischaemic heart disease

1 week
4 years
12 years
5 years

The underlying cause is “Diabetic nephropathy”.

EXAMPLES OF INCOMPLETE DESCRIPTIONS OF
CAUSE OF DEATH

Term

Additional information needed for satisfactory
coding according to international classification

Spontaneous or induced and reason if induced;
period of gestation; whether sepsis or toxae­
mia
Site and cause (e.g. tuberculous)
Abscess . . .
Anaemia . . .
Variety if primary; cause if secondary
Aortic (abdominal or thoracic), arterial, arterio­
Aneurysm . . .
venous, cardiac; arterioscleratic or syphilitic
Agranulocytic, diphtheritic, faucium strepto­
Angina . . .
coccal, Vincent’s; pectoris
Site of lesion; recent or late effects
Apoplexy . . .
Acute, Chronic or perforated
Appendicitis . . .
Arterioscelerosis . . . Whether hypertensive (benign or malignant)
nature of cardiac, cerebral and renal mani­
festations, if any
Arteriosclerotic, syphilitic; cerebral, coronary
Arteritis . . .
Acute, gonococcal, gouty, osteoarthritic, tuber­
Arthritis . . .
culous, due tojheumatic fever or rheumatoid
Cause of the condition
Ascites . . .
Asphyxia . . ,
Cause of the condition
Aorta, artery, valve of heart
Atheroma . . .
Site
Boil . . .
Bright’s disease . . . Acute, sub-acute or chronic
Acute, chronic; allergic, capillary, emphyse­
Bronchitis . . .
matous
Burn . . .
Site(s) and whether by fire, explosion, hot
object, liquid, chemical or radiation.
Site
Calculus . . .

Abortion . . .

21

22
Term

Additional information needed for satisfactory
coding according to international classification

Cancer, Carcinoma Site of primary, if known, otherwise sites of
secondary; part where it originated if of lip,
tongue, mouth, throat, intestine,
colon,
uterus; histological type, if known.
Site
Carbuncle . . .
Cardiac failure . . . Disease causing the condition
Cardiovascular . . . Whether hypertensive, coronary or renal in­
volvement
disease
Endo, myo, or per; acute, rheumatic
Carditis . . .
Caries . . .
Cause, part affected
Cause, part affected
Cellulitis . . .
Child birth . . .
Complication and whether apparent before
delivery
Rheumatic, Huntington’s gravidarum
Chorea . . .
Cause (e.g. alcoholic)
Cirrhosis of liver
Convulsion, Croup Cause
Whether fracture, internal injury, external
Crushing . . .
cause
Curvature of spine Cause, congenital or acquired
Site; congenital, multiple, hydatid, dermoid
Cyst . . .
retention
Disease causing the condition
Debility . . .
Variety
Dermatitis . . .
Disease causing the condition
Dementia . . .
Complication or independent disease causing
Diabetes . . .
death (particular care should be taken to
differentiate between diabetes as the under
lying cause and as a contributory condition)
Diarrhoea . . .
Dysentery . . .
Eclampsia . . .
Embolism . , .

Encephalitis . . .

Cause
Bacterial, Amoebic or other protozoal
Cause and whether apparent before delivery
Site and cause; associated child-birth or abor­
tion; if following operation; state condition
for which operation was performed.
Acute infectious, late effect of infectious; post
vaccinal, post-exenthematous,
idiopathic,
meningococcal, suppurative or tuberculous.

23
Term

Additional information needed for satisfactory
coding according to international classification

Acute or chronic; arteriosclerotic, hypertensive,
rheumatic or other; if rheumatic, whether
rheumatic fever was present at death
Whether puerperal infection
Endometritis . . .
Apoplectic, epileptic, eclampsia or hysteria
Fits . . .
Bone; part of skull or femur; compound;
Fracture . . .
external cause
Site and cause (diabetic, gas bacillus, senile)
Gangrene . . .
Cause
Gastritis . . .
Variety if known; site
Glioma . . .
Simple or toxic; diffuse or nodular
Goitre . . .
Haematemesis . ,. Disease causing the condition
Whether tuberculous
Haemoptysis . . .
Haemorrhage . . . Site and cause
Hemiplegia . . .
Cause and duration
Hepatitis . . .
Acute infective, chronic, alcoholic, of new
born, of pregnancy, puerperal, post-immuni­
sation, post-transfusion
Hydrocephalus . . . Congenital, tuberculous or other cause
Hypertension . . .
Benign or malignant, whether associated
arteriosclerosis, cerebrovascular, cardiac, or
renal manifestation or pregnancy
Immaturity . . .
Cause; gestation period; birth weight; asso­
ciated abnormality or disease, if any
Influenza . . .
Complications, if any
Injury . . .
Nature of injuries and parts of body injured
whether accident, suicide, homicide, war
injury; place and circumstances of accident
Insanity . . .
Form of mental disorder; direct cause of death;
underlying congenital condition, cerebral
disease; arterosclerosis, syphilis
Jaundice . . .
Catarrhal, epidemic, hacmatogenous, obstruc­
tive, toxi; cause of obstruction, or toxaemia
if any, and whether occurring during preg­
nancy or the puerperium of following immu­
nisation or transfusion. Avoid the term
“malignant” jaundice
Laryngitis . . .
Acute, chronic or tuberculous
Leukaemia . . .
Lymphatic, myeloid, monocytic; acute or
chronic.

Endocarditis . . .

24
Term

Additional information needed for satisfactory
coding according to international classification

Benign, tertian, malignant tertian, quartan,
ovale black water fever
Malformation . . . Congenital or acquired; type and organ involved
Malnutrition . . .
Congenital or due to inadequate diet, disease
or lack of care
Marasmus . . .
Cause
Myocarditis , . .
Acute rheumatic, acute non-rheuraatic, chronic
rheumatic, other chronic (but avoid using
chronic “Myocarditis” to describe degenera­
tion of the myocardium)
Neoplasm . . .
Benign or malignant; type and location; if
malignant, see Cancer
Nephritis . . .
Acute or sub-acute with oedema; chronic;
Infective or toxic; cause if known. Associa­
ted hypertension, artersclerosis, heart disease
or pregnancy
Neuritis . . .
Location; cause (e.g., alcohol, lead, rheuma­
tism)
Paraplegia . . .
Spastic due to birth injury, due to cerebral,
lesion; due to spinal lesion
Pneumonia . . .
Broncho; lobar, atypical, chronic interstitial
hypostatic, influenzal, neonatal, tuberculous
following measles
Pneumothorax . .
Cause of the condition
Rheumatic fever , . . Distinguish heart affections with active rheuma­
tic fever at death from old heart lesions left
by rheumatic fever
Rickets . . .
Active, late effects (e.g., genuvalgum) foetal,
renal or scurvy
Salpingitis . . .
Acute, chronic, gonococcal, tuberculous, post­
abortive, puerperal
Septicaemia . . .
Cause and site if localised
Ankylosing; deformans, sacro-iliac, gonococcal,
Spondylitis . . .
tuberculous
Cause, e.g., bedclothes; inhaling food, foreign
Suffocation . . .
body or smoke, chemical, mechanical, sub­
mersion, during birth
Congenital, early or late, organ affected
Syphilis . . .
Malaria . . .

25

Term

Additional information needed for satisfactory
coding according to international classification

Tetanus . . .

Mode of infection if known, e.g. slight injury,
major injury, puerperal
Organs affected including pleura and parts of
respiratory system
Site and cause, whether perforated
Cause, if known—e.g. acute, sub-acute, or
chronic nephritis, associated pregnancy or
child-birth.

Tuberculosis . . .

Ulcers . . .
Uraemia . . .

For Hospital Events

FORM NO. 8
MEDICAL CERTIFICATE OF CAUSE OF DEATH
T« be «**
, Io Registrar of Bi,ka, Bra,b

For„ . (D„;A

I. hereby certify <hat .be perron whore particulars are given below d.ed Io the hospital

at

Ward No.

a.m./p.m.

Name of deceased (Type or print)
Address of normal residence

For use by
statistical
office

.................

Marital
status :
S, M. W
or D

Religion

Occupation

days

months

CAUSE OF DEATH
(a)

Antecedent cause
Morbid conditions, if any. giving rise
to the above cause, stating underlying
condinon last.

(w

due to (or ns a consequence

If under
24 hours

minutC3

hours'

Interval between
onset & death
approx.

1. Invnediate causer

Disease, injury or complication which
caused death, not the mode of dying
such as heart failure, asthenia. etc.

Detailed list
code

Age at death
If under I year

f)

....
due to (or as a consequence of)

(c)

II. Other significant conditions contribu­
ting to the death, but not related to the
• ■ diseases or condition causing it
Accident/Suicide/Homicidc (Specify): How did injery occur 7

IF DECEASED WAS A FEMALE
Was the death associated with pregnancy ?
Was there delivery ?

Name or Rubber stamp of Institution

Yes/No
Yes/No

Serial Number
of Institution

Date of report a

Signature and address of

AHopathic/Ayorvcdic/Honiocopattuc/Unani

Physician/Mcdical Officer

(To to detached ond banded over lo Che rotative of the dcecied)

Certi&d that Sbri/Smt./Kum

Resident of
*od expired on

■

of Sbn.
~niJ admitted to the hospital on.

........

Doctor

(Medical Suppt.)

Name of Hospital

For Non-Hospital Events

FORM NO. 8A
MEDICAL CERTIFICATE OF CAUSE OF DEATH
To be sent io Registrar of Births and Deaths along with Form 4 (Drath Report)

I, hereby certify that the deceased was under tny treatment from.........

before be/sbe died on

...

....at. .........

.

...a tn./p.m.

■ For use by
statistical
office

Name of deceased (Type or print)

Address of normal residence

Sex

Age in
years

Date of
birth

Marital
status
S, M.W
or D

Religion

Age at death

Occupation

months'

days

I. Immediate cause :

>■>

hours

Detailed list
code

minu-

Interval between
onset & death
approx.

CAUSE OF DEATH
......

(a)

Disease, injury or complication
which caused death not the mode
of dying such as heart failure.
asthenia, etc

If under
24 hours

If under I year

due to (or as a consequence of)
(b)

Antecedent cause :
Morbid conditions if any, giving
rise to the above cause, stating
underlying condition last.
1J. Other significant conditions contri­
buting to the death, but not rela­
ting to the diseases or condition
causing it.

........................................... ..
due to (or os a consequence of)

(c)

Accidcnt/Suicide/Hotnicidc (Specify) : How did injury occur I

IF DECEASED WAS A FEMALE
Was the death associated with pregnancy I
Was there delivery 7

Yes/No
Yes'No

Serial Number
of Registration

Name of Medical Practitioner

Date of report

Sijn.lur. and addraa, of

Allopafbid/A.urvedk/HomocopalliicnJo.ni

Medical Practitioner

(To be detached and banded over to the relative of the deceased)
Certified that Shri/Smt /Kum

Resident of
he/shc expired on...

.......S/W/D of Shri
—•>

...at

~....was under my treatment from

i

m

a.m./p.m.

Ddctor

....

Signature and address

of the Medical Practjtloner
with Registratipo

Nq.
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