DEPARTMENT OF FORENSIC MEDICINE AND MEDICO-LEGAL

FACULTY OF MEDICINE, UNIVERSITY OF INDONESIA Jalan Salemba Raya No 6 Jakarta 10430, Fax No 62-21-3154626

CERTIFICATE OF DEATH
Name of deceased Sex Race / Nationality Age Date of death * Place of death * Post-mortem examination : : : : : : :

No of death entry

Autopsy External examination only Performed on ___________________

CAUSE OF DEATH I Disease or condition directly leading to death Antecedent causes

Morbid conditions, if any, giving rise to the above cause, stating the underlying condition last. (b) _____________________________________ Due to (or as a consequence of) ( c ) ____________________________________ (a)_____________________________________ Due to (or as a consequence of)

II Other significant conditions contributing to

the death, but not related to the disease or condition causing it.

_______________________________________ _______________________________________

MODE OF DEATH * I II Natural Unnatural a. b. c. Accident Suicide Homicide

d. Undetermined * according to police report

Certifier

Name

Signature

Date signed