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Medical Examiner and Coroner: U.S. Standard Certificate of Death Mobile App

The Medical Examiner and Coroner: U.S. Standard Certificate of Death mobile app was designed to allow medical examiners and coroners to complete a U.S. Standard Certificate of Death using a smartphone or tablet. This app generates a PDF and can be made HIPAA compliant to ensure patient privacy. Unlike with paper based forms, data submitted using GoCanvas is easily searchable in the GoCanvas Cloud.

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Take a peek inside the Medical Examiner and Coroner: U.S. Standard Certificate of Death Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

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    LOCAL FILE NO.

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    STATE FILE NO.

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    NAME OF DECEDENT

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    1. DECEDENT’S LEGAL NAME (Include AKA’s if any) (First, Middle, Last)

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    2. SEX

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    3. SOCIAL SECURITY NUMBER

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    a.

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    b.

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    Months

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    Days

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    c.

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    Hours

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    Minutes

  • Ico date

    5. DATE OF BIRTH (Mo/Day/Yr)

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    6. BIRTHPLACE (City and State or Foreign Country)

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    a.

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    b.

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    c.

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    EVER IN US ARMED FORCES?

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    9.

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    10. SURVIVING SPOUSE’S NAME (If wife, give name prior to first marriage)

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    11. FATHER’S NAME (First, Middle, Last)

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    12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)

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    a.

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    b.

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    c.

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    14. PLACE OF DEATH (Check only one: see instructions)

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    IF DEATH OCCURRED IN A HOSPITAL:

  • ...and More!

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