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Blank Michigan Death Certificate Form

The Michigan Death Certificate form is an official document that records the details surrounding an individual's death. This form is essential for legal and administrative purposes, as it provides vital information such as the deceased's name, date of birth, and cause of death. Completing the form accurately is crucial, as any missing information may result in the designation of "UNKNOWN" on the certificate.

Outline

The Michigan Death Certificate form is an essential document that plays a crucial role in the process of recording a person's death. It captures vital information about the deceased, including their name, date of birth, and date of death. Additionally, it requires details about the location of death and the decedent's residence. The form also collects demographic information such as race, education, and marital status, which can be important for statistical and historical purposes. Funeral homes, like Jansen Family Funeral Home, assist families in completing this form accurately, ensuring that all necessary fields are filled out to avoid any entries being marked as "UNKNOWN." It is important to note that the completion of this form can vary in processing time, with options for standard and expedited services available. Families should also be aware that obtaining multiple copies of the death certificate may be necessary for legal and administrative purposes. Furthermore, the form includes sections for medical certification, detailing the cause of death, which is vital for public health records. The accuracy and thoroughness of this document cannot be overstated, as it serves as a legal record of death and is often required for settling estates and accessing benefits.

Sample - Michigan Death Certificate Form

Jansen Family Funeral Home 4705 Pine Street / PO Box 77 Columbiaville, MI 48421 Daniel L. Jansen, Manager / Owner

www.jansenprofessionalservices.com Phone 810-793-6234

Michigan Death Certificate

Please Use the attached PDF of a Michigan Death Certificate to obtain the needed vitals to complete a death certificate. Please return this with DC Information. Fax 810-793-4752

How Many Death Certificates are Needed ? _____________

** Don’t assume a FREE veterans copy will be provided by all clerks offices.

Cremation	฀	Yes	฀	No
SELECT ONE	฀	Standard Service		฀	Expedited Service
Standard	- DC is completed 1-3 weeks. This service is provided in our standard
	cost already. Dc’s mailed to your funeral home.
Expedited	- An individual is placed on your DC till it is completed.
	1 Week Max		( $40 Extra ) This Service is included in all
	Direct Cremations already. Dc’s mailed to your funeral home.

Important Notes:

Item 8C - Please check on this item in order to insure accuracy.

This is not always the city listed in the mailing address.

Our funeral home will obtain the place of death, date of death, and time of death. Items - 4, 7A, 7B, 7C, 28A, 28B, 28C, 29, 30, 31, 39, 40A

Any item left blank will be listed on the certificate as “UNKNOWN”

A Proof will be faxed before Dc is filed at clerks office.

If you want Dc’s mailed to another location - Please advise us of the change

TYPE/PRINT		STATE OF MICHIGAN
IN		STATE OF MICHIGAN
IN
PERMANENT	LF
BLACK INK	LF	DEPARTMENT OF COMMUNITY HEALTH
BLACK INK	CF	CERTIFICATE OF DEATH
	CF

STATE FILE NUMBE

DECEDENT

DECEDENT	physician or institution
NAME OF	For use by
	PARENTS
	INFORMANT

DISPOSITION

CERTIFICATION

1. DECEDENT'S NAME (First Middle Last)

2. DATE OF BIRTH (Month Day Year)

3. SEX

4. DATE OF DEATH (Month Day Year)

5. NAME AT BIRTH OR OTHER NAME USED FOR PERSONAL BUSINESS (include AKA's if any)

6a. AGE - Last Birthday

6b.

UNDER 1 YEAR

6c.

UNDER 1 DAY

(Years)

7a. LOCATION OF DEATH (Enter place officially pronounced dead in 7a 7b

7c)

7b. CITY, VILLAGE, OR TOWNSHIP OF DEATH

7c. COUNTY OF DEATH

HOSPITAL OR OTHER INSTITUTION - Name (if not in either give street and number and zip code)

8a. CURRENT RESIDENCE -

8b. COUNTY

8c. LOCALITY - (check the box that describes the location)

8d. STREET AND NUMBER (Include Apt. No. if applicable)

STATE

CITY OR VILLAGE

TOWNSHIP

UNINCORPORATED PLACE

(inside limits of)

8w. ZIP CODE

9. BIRTHPLACE (City and State or Country)

10. SOCIAL SECURITY NUMBER

11. DECEDENT'S EDUCATION - What is the highest

degree or level of school completed at the time of death?

12. RACE - American Indian, White, Black, etc. if Asian

give nationality

13a. ANCESTRY - Mexican, Cuban, Arab, African, English, French, Dutch, etc.

13b. HISPANIC ORIGIN

14. WAS DECEDENT EVER IN

ie. Chinese Filipino Asian Indian etc.) (Enter all that apply)

(Enter all that apply) If American Indian race, enter principal tribe

(Yes or No)

THE U.S. ARMED FORCES?

(yes or no)

15. USUAL OCCUPATION Give kind of work done

16. KIND OF BUSINESS OR INDUSTRY

17. MARITAL STATUS - Married,

18. NAME OF SURVIVING SPOUSE (if wife

give name before

during most of working life. Do not use retired.

Never Married, Widowed, Divorced

first married)

(Specify)

19. FATHER'S NAME (First Middle Last)

20. MOTHER'S NAME BEFORE FIRST MARRIED

(First Middle Last)

21a. INFORMANT'S NAME (Type/Print)

21b. RELATIONSHIP TO

21c. MAILING ADDRESS (Street and Number or Rural Route Number City or Village State Zip Code)

DECEDENT

22. METHOD OF DISPOSITION

23a. PLACE OF DISPOSITION (Name of Cemetery Crematory or other location)

23b. LOCATION - City or Village, State

Burial Cremation Entombment

Donation Removal Storage

(Specify)

24. SIGNATURE OF MORTUARY SCIENCE LICENSEE

25. LICENSE NUMBER

26. NAME AND ADDRESS OF FUNERAL FACILITY

(of Licensee)

27a. CERTIFIER (Check only one)

28a. ACTUAL OR PRESUMED

28b. PRONOUNCED DEAD ON

28c. TIME PRONOUNCED

Certifying Physician - To the best of my knowledge, death occurred due to the cause(s) and

TIME OF DEATH

(Mo. Day Yr.)

DEAD

manner stated.

Medical Examiner - On the basis of examination, and/or investigation, in my opinion, death

29. MEDICAL EXAMINER

30. PLACE OF DEATH (Home, Hospice,

31. IF HOSPITAL, Inpatient, Outpatient,

occurred at the time, date, and place, and due to the cause(s) and manner stated.

CONTACTED? (Yes or No)

Nursing Home, Hospital, Ambulance) (Specify)

Emergency Room, DOA (Specify)

Signature and Title

27b. DATE SIGNED (Mo. Day Yr.)

27c. LICENSE NUMBER

32. MEDICAL EXAMINER'S CASE

33. NAME OF ATTENDING PHYSICIAN IF OTHER THAN

NUMBER (if applicable)

CERTIFIER (Type or Print)

34. NAME AND ADDRESS OF CERTIFYING PHYSICIAN (Type or Print)

35a. REGISTRAR'S SIGNATURE

35b. DATE FILED (Month Day Year)

CAUSE OF DEATH

MEDICAL EXAMINER

36. PART I. Enter the chain of events - diseases, injuries, or complications - that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest,

Approximate

Interval Between

or ventricular fibrillation without showing the etiology. Enter only one cause on a line.

_____________________________

Onset and Death

If diabetes was an immediate,

underlying or contributing

cause of death be sure to

record diabetes in either Part I

or Part II of the cause of

death section, as appropriate.

IMMEDIATE CAUSE (Final

disease or condition

resulting in death)

Sequentially list conditions,

IF ANY leading to the cause

listed on line a. Enter the

UNDERLYING CAUSE

(disease or injury that

37. DID TOBACCO USE

38. IF FEMALE

initiated the events resulting

in death) LAST

CONTRIBUTE TO DEATH?

PART II. OTHER SIGNIFICANT CONDITIONS contributing to death but not resulting in the underlying cause given in Part I.

Yes

Probably

Not pregnant within past year

Unknown

Pregnant at time of death

Not pregnant, but pregnant within 42 days of death

39. MANNER OF DEATH - Accident, Suicide, Homicide,

40a. WAS AN AUTOPSY

40b. WERE AUTOPSY FINDINGS AVAILABLE

Not pregnant, but pregnant 43 days to 1 year

Natural, Indeterminate or Pending (Specify)

PERFORMED?

PRIOR TO COMPLETION OF CAUSE OF

before death

(Yes or No)

DEATH? (Yes or No)

Unknown if pregnant within the past year

41a. DATE OF INJURY

41b. TIME OF INJURY

41c. DESCRIBE HOW INJURY OCCURRED

(Mo. Day Yr.)

41d. INJURY AT WORK

41e. PLACE OF INJURY - At home,

41f. IF TRANSPORTATION

41g. LOCATION - Street or RFD No.

City, Village or Twp.

State

(Yes or No)

farm, street, construction site,

INJURY - Driver/Operator,

wooded area, etc. (Specify)

Passenger, Pedestrian, etc. (Specify)

Click for PDF

Form Information

Fact Name	Detail
Governing Law	The Michigan Death Certificate is governed by the Michigan Public Health Code, Act 368 of 1978.
Issuing Authority	The Michigan Department of Community Health oversees the issuance of death certificates.
Completion Time	Standard service typically takes 1 to 3 weeks, while expedited service can be completed within 1 week.
Veterans Copies	Not all clerks' offices provide a free veterans copy; it is advisable to confirm this beforehand.
Required Information	Essential details include the decedent's name, date of birth, date of death, and place of death.
Blank Items	Any item left blank on the form will be marked as “UNKNOWN” on the death certificate.
Proof of Accuracy	A proof of the completed death certificate will be faxed for review before it is filed with the clerk's office.
Mailing Options	If certificates need to be mailed to a different location, the funeral home must be informed of the change.
Signature Requirement	The signature of a licensed mortuary science professional is required for the certificate to be valid.

Detailed Guide for Filling Out Michigan Death Certificate

Completing the Michigan Death Certificate form requires careful attention to detail to ensure all necessary information is accurately recorded. After filling out the form, it will need to be returned to the designated funeral home or relevant authority for processing. Here are the steps to fill out the form correctly:

Write the decedent's full name in the designated area (First, Middle, Last).
Enter the decedent's date of birth in the format of Month, Day, Year.
Select the sex of the decedent.
Fill in the date of death using Month, Day, Year format.
Provide the name at birth or any other name used for personal business, including any aliases.
Indicate the decedent's age at the last birthday.
If applicable, check the box for under 1 year or under 1 day.
Record the location of death, including the place where the decedent was officially pronounced dead.
List the city, village, or township of death.
Provide the county of death.
If the decedent was in a hospital or institution, include the name; otherwise, provide the street address and zip code.
Fill in the current residence details, including county and locality.
Provide the street address, including apartment number if applicable, and zip code.
Enter the birthplace, specifying the city and state or country.
Record the decedent's social security number.
Indicate the highest level of education completed by the decedent at the time of death.
Specify the decedent's race and, if applicable, ancestry.
Indicate if the decedent was ever in the U.S. Armed Forces.
Provide the usual occupation of the decedent.
Specify the kind of business or industry where the decedent worked.
Indicate the marital status of the decedent.
If married, provide the name of the surviving spouse, including the name before the first marriage.
Fill in the names of the decedent's parents (first, middle, last).
Provide the informant's name, relationship to the decedent, and mailing address.
Indicate the method of disposition (burial, cremation, etc.).
Specify the place of disposition and its location.
Have the mortuary science licensee sign and provide their license number.
Fill in the name and address of the funeral facility.
Indicate the certifier's role and fill in the date signed.
Complete the cause of death section, including immediate cause and underlying causes.
Check the box for whether an autopsy was performed and if findings were available.
Complete additional sections related to injury, if applicable.

Obtain Answers on Michigan Death Certificate

What is a Michigan Death Certificate?

A Michigan Death Certificate is an official document that records the details surrounding a person's death. It includes vital information such as the decedent's name, date of birth, date of death, and cause of death. This document is essential for legal purposes, settling estates, and claiming benefits.
How many death certificates do I need?

The number of death certificates you require can vary based on your specific needs. It's advisable to order multiple copies, especially if you plan to handle estate matters, insurance claims, or other legal processes. Keep in mind that not all clerks' offices provide free copies for veterans, so it's wise to check beforehand.
What is the difference between standard and expedited service for obtaining a death certificate?

Standard service typically takes 1 to 3 weeks, and the death certificates are mailed directly to your funeral home. This service is included in the standard cost. Expedited service, on the other hand, ensures that your request is prioritized, and you will receive the death certificate within one week for an additional fee of $40. This expedited option is included in all direct cremations.
What information is required to complete the death certificate?

To accurately complete a death certificate, several key pieces of information are needed. This includes:
- Decedent's name
- Date of birth
- Date and location of death
- Social security number
- Parents' names
- Marital status
- Cause of death
Any blank fields will be marked as “UNKNOWN,” so it's crucial to provide complete information.
What happens if I need the death certificate mailed to a different location?

If you require the death certificate to be sent to a different address, simply inform your funeral home of the change. They will ensure that the certificates are mailed to the specified location rather than the default address.
Can I review the death certificate before it is filed?

Yes, a proof of the death certificate will be faxed to you for review before it is officially filed with the clerk's office. This step allows you to verify the information and make any necessary corrections to ensure accuracy.
What should I do if I have further questions about the death certificate process?

If you have additional questions or need assistance, you can contact the Jansen Family Funeral Home at 810-793-6234. They are equipped to provide guidance and support throughout the process of obtaining a death certificate.

Common mistakes

Filling out the Michigan Death Certificate form is a crucial task that must be approached with care. Many people make mistakes that can lead to complications later. One common error is assuming that all clerks’ offices automatically provide a free veterans copy of the death certificate. This assumption can cause delays and confusion, especially for families expecting to receive this document without any additional cost.

Another frequent mistake involves leaving certain items blank. For instance, items such as 4, 7A, 7B, and others must be filled out completely. If any of these fields are left blank, they will be marked as “UNKNOWN” on the final certificate. This can create issues for record-keeping and may complicate future legal matters. It is essential to ensure that all required information is accurately provided to avoid this pitfall.

Additionally, some individuals fail to verify the accuracy of the location of death. Item 8C can often be overlooked, leading to discrepancies between the official records and the actual circumstances. The city listed in the mailing address may not always match the place where the individual was pronounced dead. It is vital to double-check this information to ensure that it reflects the correct location.

Many people also neglect to specify the method of disposition, which is another critical section of the form. Whether the individual is to be buried, cremated, or donated should be clearly indicated. Failing to do so can lead to misunderstandings between family members and the funeral home, complicating the process during an already difficult time.

Lastly, individuals often forget to include the social security number of the decedent. This detail is important for various administrative purposes, including the processing of benefits and other legal matters. Omitting this information can lead to unnecessary delays and complications, making it essential to include it in the submission.

Documents used along the form

The Michigan Death Certificate is a crucial document for recording the vital statistics of a deceased individual. Along with this form, several other documents are often required to facilitate various processes following a death. Here are four common forms and documents that may accompany the Michigan Death Certificate:

Affidavit of Heirship: This document establishes the rightful heirs of the deceased's estate. It is often used when the deceased did not leave a will, helping to clarify who inherits the property and assets.
Will: If the deceased left a will, this document outlines their wishes regarding the distribution of their assets. It may also name an executor responsible for managing the estate.
Funeral Home Contract: This contract details the services agreed upon with the funeral home. It typically includes information about the type of service, costs, and any special requests made by the deceased or their family.
Social Security Notification: This form is used to notify the Social Security Administration of the individual's death. It helps ensure that any benefits are properly managed and that the deceased's records are updated.

Each of these documents plays a significant role in managing the legal and financial aspects that arise after a death. Properly completing and submitting them can help streamline the process for surviving family members.

Similar forms

The Michigan Death Certificate form shares similarities with several other important documents. Below is a list detailing these documents and their similarities:

Birth Certificate: Like the death certificate, a birth certificate is an official document that records vital information. It includes personal details such as the individual's name, date of birth, and place of birth, similar to how a death certificate captures the decedent's name, date of death, and place of death.
Marriage Certificate: A marriage certificate serves as a legal document that confirms the union between two individuals. It includes names, dates, and locations, paralleling the death certificate's function of documenting significant life events and personal information.
Divorce Decree: A divorce decree is a legal document that finalizes the dissolution of a marriage. It contains essential details such as the names of the parties involved and the date of the divorce, akin to the death certificate's focus on critical life milestones and personal data.
Social Security Death Index (SSDI): The SSDI is a database that records the deaths of individuals who held a Social Security number. It includes vital statistics such as the individual's name, date of birth, and date of death, similar to the information captured on a death certificate.

Dos and Don'ts

When filling out the Michigan Death Certificate form, it’s important to be thorough and accurate. Below is a list of things you should and shouldn't do:

Do use permanent black ink when filling out the form.
Don't leave any items blank; any unanswered fields will be marked as “UNKNOWN.”
Do double-check the place of death to ensure it matches official records.
Don't assume that all clerks' offices will provide a free veterans copy.
Do provide the full name of the decedent, including any known aliases.
Don't forget to include the correct date and time of death.
Do indicate the decedent's highest level of education completed.
Don't overlook the importance of accurate information regarding the decedent's race and ancestry.
Do specify the method of disposition clearly, whether burial, cremation, or other.
Don't forget to provide the informant's name and relationship to the decedent.

By following these guidelines, you can help ensure that the death certificate is completed correctly and efficiently.

Misconceptions

All clerks provide free veterans copies. Many assume that all clerk offices will automatically provide a free copy of the death certificate for veterans. This is not always the case. It's essential to verify with the specific clerk's office.
Only one death certificate is needed. Families often underestimate the number of copies required. Depending on circumstances, multiple copies may be necessary for insurance claims, legal matters, or personal records.
Blank fields will be filled in later. If any items are left blank on the form, they will be marked as “UNKNOWN” on the certificate. It is crucial to provide complete information.
Expedited service guarantees faster processing. While expedited service is available, it does not guarantee instant processing. It typically takes up to one week, but delays can still occur.
All information is automatically verified. Families might think that all details will be cross-checked for accuracy. However, it is the responsibility of the informant to ensure that the information provided is correct.
Only the funeral home needs to fill out the form. The informant, who is often a family member, must provide specific information. This includes personal details about the deceased and their relationship to the informant.
Death certificates are only for legal purposes. While they are often required for legal matters, many families also want copies for personal keepsakes or memorials.
Time of death is not important. The exact time of death is a crucial piece of information that must be accurately recorded. This can impact various legal and medical considerations.

Key takeaways

When filling out the Michigan Death Certificate, ensure you use the attached PDF to gather all necessary information accurately.
It is important to determine how many copies of the death certificate are needed, as not all clerks' offices provide a free veterans copy.
Choose between standard and expedited service for processing the death certificate. Standard service typically takes 1-3 weeks, while expedited service guarantees completion within one week for an additional fee.
Pay close attention to Item 8C, as this may differ from the city listed in the mailing address and is crucial for accuracy.
Any item left blank on the form will be marked as “UNKNOWN” on the death certificate, so it is vital to complete all sections.
A proof of the death certificate will be faxed to you before it is filed with the clerk's office, allowing for any necessary corrections.
Clearly indicate if the death certificate should be mailed to a different location than the funeral home.
Use permanent black ink when filling out the form to ensure legibility and compliance with state requirements.
Be thorough when providing details about the decedent, including their full name, date of birth, and other personal information.
Consult with the funeral home for assistance with obtaining the place, date, and time of death, as they will handle these details on your behalf.