TAIWAN R.O.C. STANDARD
CERTIFICATE OF DEATH
Registration No.( dept. use only )
TO BE FILLED OUT BY ISSUER
1. DECEDENT’S NAME (First, Middle, Last) 2. SEX 3. IDENTIFICATION NUMBER
4. REGISTERED PERMANENT RESIDENCE (Street and number, city, town, country)
5a. DATE OF BIRTH (Month, Day, Year) 5b. TIME OF BIRTH (For death within one week after birth)
AM Hour Minutes
6a. DATE OF DEATH (Month, Day, Year) 6b. TIME OF DEATH
AM Hour Minutes
7a. LOCATION OF DEATH 7b. PLACE OF DEATH
(Street and number, city, town, country) Hospital Clinic Midwifery Center
Own Residence Others
8. MANNER OF DEATH
Death from Illness or Natural Death Accident Suicide Homicide Could not be Determined
9a. KIND OF BUSINESS/INDUSTRY 9b. DECEDENT’S USUAL OCCUPATION
10. MARITAL STATUS
Never Married Married Divorced Widowed Unknown
11. CAUSE OF DEATH (Enter the diseases, injuries, or complications that caused the death. Approximate
Do not enter the mode dying, such as heart failure or respiratory arrest.) Interval between
PART I. Onset and Death
IMMEDIATE CAUSE (Final
disease or condition resulting
in death ) a.
DUE TO (OR AS A CONSEQUENCE OF) :
Sequentially list conditions,
if any, leading to immediate b.
cause. Enter UNDERLYING DUE TO (OR AS A CONSEQUENCE OF) :
CAUSE (Disease or injury
that initiated events resulting c.
in death ) LAST
PART II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I.
THIS IS TO CERTIFY THAT THE ABOVE STATEMENT IS TRUE.
Name and License Number of Certifying Physician:
Name and Practice License Number of Hospital (Clinic):
Address of Hospital (Clinic): No. 325, Sec. 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan R.O.C.
Date Signed (Month, Day, Year) :
INSTRUCTIONS 1. This certificate shall be filled out after death by physician of hospital (clinic)
or administrative and judicial official attending autopsy.
2. For either administrative or judicial official attending autopsy, items 11 and 12
shall be certified by the person attending autopsy and his/her institution.
3. Each item shall be filled out and information in all items shall be in agreement.
4. Instruction for selected items:
Item 5b. TIME OF BIRTH
Enter the exact time that death occurred if under 1 week.
Item 9a. KIND OF BUSINESS/INDUSTRY
Enter the kind of business or industry to which the occupation
listed in item 9b was related, such as fishing, financing, public
agency and national defense, or retail trade.
Item 9b. DECEDENT’S USUAL OCCUPATION
Enter the recent occupation of the decedent, such as director and
chief executive, computer programmer, teacher, ocean fishery
worker, plasterer, or cook.
Item 11 CAUSE OF DEATH
In Part I, the immediate cause of death is reported on line (a).
Antecedent conditions, if nay, that gave rise to the cause are reported
on lines (b) and (c). Not entering is necessary on lines (b) and (c) if
the immediate cause of death on line (a) describes completely the
sequence of events. Only one cause should be entered on a line.
Additional lines may be added if necessary. Provide the best
estimate of the interval between the onset of each condition and
death. Do not leave the space for the interval blank; if unknown, so
In Part II, enter other important diseases or conditions that
contributed to death but did not result in the underlying cause of
death given in Part I.