For Original  Record

STATE OF ILLINOIS

CORRECTED CAUSE OF DEATH CERTIFICATION

Concerning the death record of:

who died at

in the County of

, Illinois, on the

day of

, 19

I HEREBY CERTIFY that the death certificate for the person named above should be corrected as follows, to reflect post mortem and/or other findings which were not available when the cause of death was initially certified on the certificate of death:

18.

DEATH WAS CAUSED BY:

[ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c)

APPROXIMATE INTERVAL

BETWEEN ONSET AND DEATH

PART I

IMMEDIATE CAUSE

CONDITIONS IF ANY

{

(a)

WHICH GIVE RISE TO

DUE TO OR AS A CONSEQUENCE OF:

IMMEDIATE CAUSE (a)

(b)

STATING THE UNDERLYING

DUE TO OR AS A CONSEQUENCE OF:

CAUSE LAST.

(c)

PART II. OTHER SIGNIFICANT CONDITIONS: CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART 1(a)

AUTOPSY (Yes/No)

19a.

IF YES,  WERE FINDINGS CONSIDERED IN DETERMINING  CAUSE OF DEATH

19b.

DATE OF OPERATION IF ANY

MAJOR FINDINGS OF OPERATION

20a.

20b.

Signature

, M.D.,

Date

(Attending Physician or Pathologist)

Address

Accepted for filing on the

day of

, 19

.  By

Title

VR-400.2 (10/70r)

OFFICE OF VITAL RECORDS

-

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

-

SPRINGFIELD 62706