The Michigan Death Certificate form is an official document that records vital information about a deceased individual. This form is essential for legal and administrative purposes, including burial or cremation arrangements. For assistance in completing the form, click the button below.
When dealing with the passing of a loved one, the Michigan Death Certificate form becomes a crucial document that helps facilitate the necessary legal and administrative processes. This form captures essential information about the deceased, including their full name, date of birth, and date of death, which are vital for legal records and for settling estates. Additionally, it requires details about the decedent's place of death, whether it was at home, in a hospital, or elsewhere, as well as their social security number and educational background. The form also includes sections for the informant—typically a family member or close associate—who provides personal information about the deceased, such as their race, ancestry, and marital status. It is important to complete all sections accurately; any unanswered items will be marked as “UNKNOWN,” which can complicate future processes. The Michigan Death Certificate form also outlines options for obtaining multiple copies, including standard and expedited services, with clear instructions on how to submit the completed form. Understanding these components can ease some of the burden during a challenging time, ensuring that all necessary information is gathered and submitted correctly.
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
PERMANENT
LF
BLACK INK
DEPARTMENT OF COMMUNITY HEALTH
CF
CERTIFICATE OF DEATH
STATE FILE NUMBE
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)
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
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
M
(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
d.
If diabetes was an immediate,
underlying or contributing
a.
cause of death be sure to
record diabetes in either Part I
or Part II of the cause of
death section, as appropriate.
b.
IMMEDIATE CAUSE (Final
disease or condition
resulting in death)
Sequentially list conditions,
c.
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.
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
DEATH? (Yes or No)
Unknown if pregnant within the past year
41a. DATE OF INJURY
41b. TIME OF INJURY
41c. DESCRIBE HOW INJURY OCCURRED
41d. INJURY AT WORK
41e. PLACE OF INJURY - At home,
41f. IF TRANSPORTATION
41g. LOCATION - Street or RFD No.
City, Village or Twp.
State
farm, street, construction site,
INJURY - Driver/Operator,
wooded area, etc. (Specify)
Passenger, Pedestrian, etc. (Specify)
Completing the Michigan Death Certificate form requires careful attention to detail. The information provided will be used for official records and must be accurate. Once the form is filled out, it should be submitted as directed to ensure proper processing.
To complete a Michigan Death Certificate, several key pieces of information are needed. This includes:
Any item left blank will be marked as "UNKNOWN" on the certificate. It’s crucial to ensure accuracy, especially for the location of death and the names provided.
The time it takes to obtain a death certificate can vary based on the service selected. For standard service, it typically takes 1 to 3 weeks. However, if expedited service is chosen, you can receive it within 1 week for an additional fee of $40. The expedited service ensures that the individual is placed on the death certificate until it is completed.
While veterans may be eligible for free copies of their death certificates, this is not guaranteed. It’s important to check with the specific clerk's office where the certificate is being filed. Some offices may not provide free copies, so it’s advisable to confirm this in advance.
If you need the death certificates sent to a different address than the funeral home, you should inform the funeral home of this change. Make sure to provide the complete mailing address where you want the documents sent. This will ensure that the certificates are delivered to the correct location.
Leaving Items Blank: Failing to complete all required fields can lead to the designation of “UNKNOWN” on the death certificate. Ensure that items such as the decedent's name, date of death, and location of death are filled out accurately.
Incorrect Information: Providing inaccurate details, such as the decedent's date of birth or social security number, can cause delays and complications. Double-check all information before submission.
Assuming Free Copies: Not all clerks’ offices provide a free copy for veterans. It is essential to inquire beforehand to avoid unexpected costs.
Neglecting to Specify the Disposition Method: Failing to indicate whether the body will be buried, cremated, or otherwise disposed of can lead to confusion. Always select the appropriate method clearly.
Ignoring the Importance of Item 8C: This item may not reflect the city listed in the mailing address. Verify this information to ensure accuracy.
Inaccurate Ancestry or Race Information: Not providing complete or accurate ancestry and race information can result in issues later. Be sure to include all relevant details.
Failure to Communicate Changes: If there are any changes to where the death certificates should be mailed, it is crucial to inform the funeral home promptly. Delays can occur if this information is not communicated effectively.
When dealing with the loss of a loved one, several important documents accompany the Michigan Death Certificate. Each document serves a specific purpose in managing the affairs of the deceased and ensuring that legal and administrative processes are followed correctly. Below is a list of commonly used forms and documents that may be required alongside the Michigan Death Certificate.
Gathering these documents can simplify the process of managing the estate and ensure that the wishes of the deceased are honored. It is advisable to consult with a legal professional to navigate these requirements effectively.
The Michigan Death Certificate form shares similarities with the Birth Certificate. Both documents serve as vital records that establish important life events. A birth certificate records the details surrounding the birth of an individual, such as the date, time, and place of birth, along with parental information. Similarly, the death certificate documents the circumstances of a person's death, including the date, time, and location, as well as details about the deceased's parents. Both forms require verification from authorized personnel, ensuring that the information provided is accurate and legally recognized.
Another document comparable to the Michigan Death Certificate is the Marriage Certificate. This document serves as official proof of a marriage and includes vital information such as the names of the individuals involved, the date of the marriage, and the location where the ceremony took place. Like the death certificate, a marriage certificate is often required for legal purposes, such as changing a name or settling estates. Both documents are essential for establishing personal identity and legal status within various contexts.
The Divorce Decree is another important document that shares characteristics with the Michigan Death Certificate. This legal document outlines the terms of a divorce, including the division of assets, custody arrangements, and other relevant details. Both the divorce decree and death certificate require official signatures and must be filed with the appropriate governmental authority to be valid. They serve as formal records of significant life changes, impacting an individual's legal rights and responsibilities.
The Social Security Death Index (SSDI) is also similar to the Michigan Death Certificate. The SSDI is a database that contains information about deceased individuals who had Social Security numbers. It includes details such as the person's name, date of birth, date of death, and last known residence. Both documents are used to confirm an individual's death and may be required for various administrative processes, including settling estates and claiming benefits.
Another document that parallels the Michigan Death Certificate is the Will. A will is a legal document that outlines an individual's wishes regarding the distribution of their assets after death. While a death certificate serves to confirm that a person has passed away, a will provides guidance on how their estate should be managed. Both documents are critical in the context of estate planning and can significantly impact the lives of surviving family members.
The Certificate of Stillbirth is another document that shares similarities with the Michigan Death Certificate. This certificate is issued when a baby is stillborn and provides essential details such as the date of stillbirth, the baby's name, and the parents' information. Both certificates serve as official records of a person's life event, albeit in different circumstances, and are often used for emotional closure and legal purposes.
Finally, the Autopsy Report is a document that can be compared to the Michigan Death Certificate. This report provides detailed information about the cause of death, typically following a medical examination of the deceased. While the death certificate summarizes the essential details of a person's passing, the autopsy report delves into the medical aspects. Both documents are crucial in understanding the circumstances surrounding a death and may be necessary for legal investigations or insurance claims.
When filling out the Michigan Death Certificate form, it’s essential to approach the task with care. Here’s a list of things you should and shouldn’t do to ensure accuracy and compliance.
Understanding the Michigan Death Certificate form can be challenging. Here are ten common misconceptions that people often have:
Ensure you have the Michigan Death Certificate form ready and accessible, as it contains vital information needed for completion.
Determine the number of death certificates required before filling out the form. This can vary based on personal and legal needs.
Note that a free veterans copy may not be provided by all clerks' offices, so it's important to confirm this ahead of time.
Choose between Standard Service and Expedited Service when submitting your request. The expedited option incurs an additional fee but offers quicker processing.
Pay close attention to Item 8C, as it requires accuracy regarding the city of death, which may differ from the mailing address.
All items left blank on the form will be marked as “UNKNOWN” on the death certificate, so ensure every field is filled out as completely as possible.
A proof of the death certificate will be faxed to you for review before it is officially filed with the clerk's office.
If you need the death certificates mailed to a different location, inform the funeral home of this change at the time of submission.