Illinois Death Certificate

1. Decedent's Legal Name (

2. Sex

3. Date of Death (Month/Day/Year) (Spell Month)

4. County of Death

5a. Age at Last Birthday (Years)

5b. Under 1 Year (Months/Days)

5c. Under 1 Day (Hours/Minutes)

6. Date of Birth (Month/Day/Year)

7a. City or Town

7b. Hospital or Other Institution Name (if not in either, give street and number)

7c. Place of Death

7c. Place of Death (Check only one: see instructions)

If Death Occurred in a Hospital

Inpatient

Emergency Room/ Out Patient

Dead on Arrival

If Death Occurred Somewhere Other Than a Hospital

Hospice Facility

Nursing Home/ Long-term Care Facility

Decedent's Home

Other (Specify)

7c. Specify Other

8. Birthplace (City and State or Foreign Country)

9. Social Security Number

10. Status at Time of Death

11. Surviving Spouse/ Civil Union Partner

13a. Residence (Street and Number)

13b. Apt No.

13c. City or Town

13e. County

13f. State

13g. Zip Code

14. Father/ Co-Parent's Name Prior to First Marriage/ Civil Union (First, Middle, Last)

15. Mother/ Co-Parent's Name prior to First Marriage/ Civil Union (First, Middle, Last)

16a. Informant's Name

16b. Relationship

16c. Mailing Address (Street and No., City or Town, State, ZIP Code)

17. Method of Disposition

17. Other (Specify)

18. Place of Disposition (Name of Cemetery, Crematory, Other)

19. Location - City, Town and State

20. Date of Disposition (Month/Day/Year)

Free Text

47. Decedent's Education- Check the box that best describes the highest degree of level of school completed at the time of death

Free Text

48. Decedent of Hispanic Origin? Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check the "No" Box if the decedent is not Spanish/Hispanic/Latino.

47. Decedent's Education

8th Grade or Less

9th-12th Grade

High School Graduate or GED Completed

Some College Credit, but No Degree

Associate Degree (e.g., AA, AS)

Bachelor's Degree (e.g. BA, AB, BS)

Master's Degree ( e.g. MA, MS, MEng, MEd, MSW, MBA)

Doctorate (e.g. PhD, EdD) or Prof. Degree (e.g. MD, DDS, DVM, LLB, JD)

Unknown

48. Decedent of Hispanic Origin?

No, Not Spanish/Hispanic/Latino

Yes, Mexican, Mexican American, Chicano

Yes, Puerto Rican

Yes, Cuban

Yes, Other Spanish/Hispanic/ Latino

48. Other

Free Text

49. Decedent's Race - Check One or more races to indicate what the decedent considered himself or herself to be.

49. Decedent's Race

49. Other

50. Decedent's Usual Occupation (Indicate type of work done during most of working life. Do not use Retired)

51. Business/ Industry (Enter Type of Business or Industry, Not Company Name)

Illinois Death Certificate

A Year of Grief Support