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Free Michigan Death Certificate Template in PDF

The Michigan Death Certificate is an official document that records the details surrounding an individual's death. It serves as a vital record for legal, medical, and personal purposes, ensuring that the deceased's information is accurately documented. Completing this form correctly is crucial, as any inaccuracies may lead to complications in the processing of the death certificate.

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The Michigan Death Certificate form is a crucial document that serves as an official record of an individual's death. It is utilized by funeral homes, healthcare providers, and state officials to ensure accurate reporting and compliance with legal requirements. The form includes essential information such as the decedent's name, date of birth, date of death, and place of death, along with details regarding their education, race, and marital status. Additionally, it requires the identification of the informant, who is typically a family member or close associate of the deceased. Proper completion of the form is vital; any blank fields will default to "UNKNOWN," which can lead to complications in record-keeping. The form also outlines options for standard and expedited services, allowing families to choose how quickly they wish to receive certified copies of the death certificate. It is important to note that not all clerks' offices provide free copies for veterans, and families should confirm their needs ahead of time. Furthermore, the form contains sections for certifying the cause of death, which must be filled out accurately by a licensed physician or medical examiner. Ensuring that all details are correct is paramount, as inaccuracies can have lasting implications for estate matters and other legal proceedings.

Form Example

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)

▼ Michigan Death Certificate PDF Form

Document Specs

Fact Name	Details
Governing Law	The Michigan Death Certificate is governed by the Michigan Public Health Code, Act 368 of 1978.
Required Information	Essential details include the decedent's name, date of birth, date of death, and location of death.
Blank Items	Any item left blank on the form will be marked as “UNKNOWN” on the certificate.
Processing Time	Standard processing for death certificates takes 1-3 weeks, while expedited service is available for completion within 1 week for an additional fee.
Veterans Copies	Not all clerk offices provide free copies for veterans; it's important to confirm this beforehand.
Signature Requirement	A licensed mortuary science professional must sign the certificate, affirming the accuracy of the information.
Proof of Accuracy	A proof of the death certificate will be faxed for review before it is filed with the clerk's office.

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