Fill Your Michigan Death Certificate Template

The Michigan Death Certificate is an official document that records the details surrounding an individual's death. This form is essential for legal and administrative purposes, including the issuance of burial permits and the settlement of estates. Completing this form accurately is crucial, as any missing information may result in delays or complications.

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Fill Your Michigan Death Certificate Template

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Documents used along the form

When dealing with the passing of a loved one, several documents accompany the Michigan Death Certificate form. Each of these documents serves a specific purpose in the process of managing the deceased's affairs and ensuring that all legal requirements are met.

Affidavit of Heirship: This document is used to establish the rightful heirs of the deceased. It is often necessary for settling estates, especially when there is no will present.
Will: If the deceased left a will, it outlines how their assets should be distributed. It is a crucial document for probate proceedings and may need to be filed with the local probate court.
Georgia WC-3 Form: This form is essential for disputing a worker's compensation claim and notifies the State Board of Workers' Compensation about the challenge. Understanding its proper use is key to navigating the claims process; for more information, visit Forms Georgia.
Application for Probate: This form is filed with the probate court to initiate the legal process of administering the deceased's estate. It includes details about the deceased and their assets.
Insurance Claim Forms: If the deceased had life insurance, these forms must be completed to claim the benefits. They typically require a copy of the death certificate and information about the policy.
Social Security Administration Forms: These forms are necessary to report the death to the Social Security Administration. They may also be required to claim any survivor benefits available to the deceased's family.

Understanding these documents can ease the burden during a difficult time. It's important to gather them promptly to ensure that the necessary legal and financial processes proceed smoothly.

Michigan Death Certificate Preview

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)

Similar forms

Birth Certificate: Like the death certificate, a birth certificate records vital information about an individual, including their name, date of birth, and place of birth. Both documents serve as legal proof of identity and are used for various administrative purposes.
Affidavit of Gift Form: To facilitate the gifting process legally, refer to our official Affidavit of Gift documentation to ensure all ownership transfers are properly recorded.
Marriage Certificate: This document provides official confirmation of a marriage, detailing the names of the spouses, date, and location of the marriage. Similar to a death certificate, it serves as a legal record for personal status changes.
Divorce Decree: A divorce decree is a legal document that finalizes the dissolution of a marriage. It includes information about the parties involved and the date of the divorce, paralleling the death certificate's function of documenting significant life events.
Medical Examiner's Report: This report details the findings of a medical examination following a death. It includes cause and manner of death, akin to the information provided in a death certificate, which summarizes the circumstances surrounding a person's passing.
Will: A will outlines the distribution of an individual's assets after death. While it does not serve as a vital record, it is a crucial legal document that comes into play after a person's death, similar to how a death certificate is used for estate matters.

Misconceptions

Here are ten common misconceptions about the Michigan Death Certificate form, along with clarifications to help you understand the process better.

All clerks provide a free veteran's copy of the death certificate. Not all clerks' offices offer this service. It's essential to check with your local office.
There is no limit to the number of death certificates you can request. While you can request multiple copies, consider how many you truly need, as each may incur a fee.
Filling out the form correctly is not crucial. Inaccurate information can lead to delays or complications. Always double-check your entries.
Death certificates are processed immediately. Standard processing can take 1-3 weeks, while expedited service costs extra and takes up to one week.
Leaving items blank on the form is acceptable. Any blank item will be marked as “UNKNOWN,” which may not be ideal for your records.
Only the funeral home can fill out the entire form. While they assist, family members or informants can provide necessary information too.
The place of death is always the same as the residence. This is not true; the place where the death is officially pronounced may differ from the home address.
All information about the decedent's education is optional. This information is required and can impact the completion of the certificate.
Once filed, the death certificate cannot be changed. Corrections can be made, but they may require additional paperwork and time.
Death certificates are only needed for burial or cremation. They are often required for legal purposes, such as settling estates or claiming insurance.

Detailed Instructions for Using Michigan Death Certificate

After gathering the necessary information, filling out the Michigan Death Certificate form requires attention to detail. Each section must be completed accurately to ensure that the certificate is processed correctly. Below are the steps to follow when completing the form.

Start by writing the decedent's full name in the designated area.
Enter the date of birth in the format of month, day, and year.
Select the sex of the decedent.
Provide the date of death in the same format as the date of birth.
If applicable, include the name at birth or any other names used.
Indicate the decedent's age at the last birthday.
Check the appropriate boxes if the decedent was under one year or under one day old.
Fill in the location of death, including the place where the decedent was officially pronounced dead.
Provide the city, village, or township of death.
List the county of death.
Include the name of the hospital or institution, or provide the street address if applicable.
Fill out the current residence information, including the street address and zip code.
Enter the birthplace of the decedent.
Provide the social security number of the decedent.
Indicate the highest level of education completed by the decedent.
Specify the decedent's race and ancestry.
State whether the decedent was ever in the U.S. Armed Forces.
List the usual occupation and kind of business or industry.
Indicate the marital status and name of the surviving spouse.
Provide the names of the decedent's parents.
Fill in the informant's name, relationship to the decedent, and mailing address.
Indicate the method of disposition (burial, cremation, etc.).
Provide the place and location of disposition.
Have the signature of the mortuary science licensee included.
Complete the certification section, including the certifying physician's information and signature.
Fill out the cause of death section, detailing the chain of events leading to death.
Answer questions regarding tobacco use and pregnancy status if applicable.
Complete the manner of death and any injury-related information if necessary.

Dos and Don'ts

When filling out the Michigan Death Certificate form, it’s essential to approach the task with care. Here are some important dos and don’ts to keep in mind:

Do ensure that all required fields are filled out completely. Any item left blank will be marked as “UNKNOWN” on the certificate.
Do double-check the accuracy of the information provided, especially the location of death and the date of death.
Do communicate any changes regarding where the death certificates should be mailed. This helps prevent delays.
Do use permanent black ink when filling out the form to ensure legibility.

Don’t assume that a free veterans copy will be provided by all clerk offices. Always confirm this with the relevant office.
Don’t forget to check Item 8C for accuracy, as it may not always reflect the city listed in the mailing address.
Don’t leave any fields blank, as this can lead to complications in processing the death certificate.
Don’t overlook the need for a proof to be faxed before the death certificate is filed with the clerk's office.

Fill Your Michigan Death Certificate Template

Documents used along the form

Michigan Death Certificate Preview

Similar forms

More PDF Documents

Misconceptions

Detailed Instructions for Using Michigan Death Certificate

Dos and Don'ts