Form R-360 "Death Certificate Medical Certifier Worksheet" - Massachusetts

What Is Form R-360?

This is a legal form that was released by the Massachusetts Registry of Vital Records and Statistics - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 7, 2014;
  • The latest edition provided by the Massachusetts Registry of Vital Records and Statistics;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form R-360 by clicking the link below or browse more documents and templates provided by the Massachusetts Registry of Vital Records and Statistics.

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Download Form R-360 "Death Certificate Medical Certifier Worksheet" - Massachusetts

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Commonwealth of Massachusetts
Registry of Vital Records and Statistics
DEATH CERTIFICATE MEDICAL CERTIFIER WORKSHEET
Form R-360 07012014
Please complete the information pertaining to the decedent as well as the cause of death information as this document will be used to
create the legal death certificate. PLEASE PRINT NEATLY TO HELP WITH DATA ENTRY.
DECEDENT – NAME
FIRST
MIDDLE
LAST
GENERATIONAL ID
PLACE OF DEATH – CITY/TOWN
DATE OF DEATH (Month DD, YYYY)
SEX
DATE OF BIRTH (Month DD, YYYY)
MEDICAL RECORD NUMBER
PLACE OF DEATH
 Hospital-Inpatient
 Hospital-ER/Outpatient
 Hospital-DOA  Decedent’s Residence
 Hospice Facility
 Nursing Home/Long Term Care
 Assisted Living Facility or Rest Home
 Other _________________________
HOSPITAL OR OTHER INSTITUTION – NAME (
If not in either, provide street and number
)
PART I – CAUSE OF DEATH – SEQUENTIALLY LIST IMMEDIATE CAUSE THEN ANTECEDENT CAUSES THEN UNDERLYING CAUSE
APPX INTERVAL
a) Immediate
Cause
b) Due to
c) Due to
d) Due to
PART II – OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH
M.E. NOTIFIED?
AUTOPSY PERFORMED?
 Yes
 No
 M.E.  Priv  No
AUTOPSY FINDINGS AVAILABLE PRIOR TO COMPLETING CAUSE OF DEATH?
 Yes
 No
MANNER OF DEATH
M.E. CASE NUMBER
 Natural
ALL OTHER MANNER OF DEATH CASES ARE REQUIRED TO BE REFERRED TO THE MEDICAL EXAMINER
TIME OF
 AM
 AM
MANNER OF DEATH
INJURY AT
DATE OF INJURY (Month DD, YYYY)
APPX
INJURY
WORK?
TIME OF
 Accident
 Homicide
 Suicide  Pending investigation
DEATH
 PM
 PM
 Yes
 Therapeutic Complication
 Could not be determined
 Mil.
 Mil.
 No
 Other (Specify)
______________________________
PLACE OF INJURY
TRANSPORTATION INJURY
 Driver/Operator  Passenger  Pedestrian  Not Applicable
 Other (Specify) __________________________________
LOCATION/ADDRESS OF INJURY
M.E. DATE PRONOUNCED (Month DD, YYYY)
 AM  PM  Military
DESCRIBE HOW INJURY OCCURRED
M.E. TIME PRONOUNCED
IF FEMALE, PREGNANCY STATUS AT TIME OF DEATH
DID TOBACCO USE CONTRIBUTE TO DEATH?
 Not pregnant within the past year  Pregnant at time of death  Not pregnant, but pregnant within 42 days of
 Yes
 No
death  Not pregnant, but pregnant within 43 days to 1 year before death  Unknown, if pregnant in past year
 Probably  Unknown
MEDICAL CERTIFIER INFORMATION – NAME/TITLE
 AM  PM
HOUR OF DEATH
 Military
MEDICAL CERTIFIER INFORMATION – ADDRESS
LICENSE #
MEDICAL CERTIFIER DESIGNATION
 Certifier in attendance at time of death  Physician in charge of patient’s care  Nurse Practitioner in attendance at time of death
 Nurse Practitioner in charge of patient’s care
 Medical Examiner
MEDICAL CERTIFIER FAX NUMBER TO
MEDICAL CERTIFIER TELEPHONE NUMBER
RECEIVE ATTESTATION FORM
PROVIDER IN CHARGE OF PATIENT’S CARE – NAME/TITLE
 R.N.  P.A.  N.P.
 AM
RN/ PA/ NP
IF YES, DATE (Month DD, YYYY)
IF YES,
PRONOUNCER INFORMATION – NAME
TITLE
PRONOUNCEMENT?
TIME
Mil.
 PM
 Yes
 No
DATE SIGNED (Month DD, YYYY)
On the basis of examination and/or investigation in my opinion death occurred at the time, date, and place and due to the
cause(s) stated
.
Signature and Title of Medical
Certifier Required.
Commonwealth of Massachusetts
Registry of Vital Records and Statistics
DEATH CERTIFICATE MEDICAL CERTIFIER WORKSHEET
Form R-360 07012014
Please complete the information pertaining to the decedent as well as the cause of death information as this document will be used to
create the legal death certificate. PLEASE PRINT NEATLY TO HELP WITH DATA ENTRY.
DECEDENT – NAME
FIRST
MIDDLE
LAST
GENERATIONAL ID
PLACE OF DEATH – CITY/TOWN
DATE OF DEATH (Month DD, YYYY)
SEX
DATE OF BIRTH (Month DD, YYYY)
MEDICAL RECORD NUMBER
PLACE OF DEATH
 Hospital-Inpatient
 Hospital-ER/Outpatient
 Hospital-DOA  Decedent’s Residence
 Hospice Facility
 Nursing Home/Long Term Care
 Assisted Living Facility or Rest Home
 Other _________________________
HOSPITAL OR OTHER INSTITUTION – NAME (
If not in either, provide street and number
)
PART I – CAUSE OF DEATH – SEQUENTIALLY LIST IMMEDIATE CAUSE THEN ANTECEDENT CAUSES THEN UNDERLYING CAUSE
APPX INTERVAL
a) Immediate
Cause
b) Due to
c) Due to
d) Due to
PART II – OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH
M.E. NOTIFIED?
AUTOPSY PERFORMED?
 Yes
 No
 M.E.  Priv  No
AUTOPSY FINDINGS AVAILABLE PRIOR TO COMPLETING CAUSE OF DEATH?
 Yes
 No
MANNER OF DEATH
M.E. CASE NUMBER
 Natural
ALL OTHER MANNER OF DEATH CASES ARE REQUIRED TO BE REFERRED TO THE MEDICAL EXAMINER
TIME OF
 AM
 AM
MANNER OF DEATH
INJURY AT
DATE OF INJURY (Month DD, YYYY)
APPX
INJURY
WORK?
TIME OF
 Accident
 Homicide
 Suicide  Pending investigation
DEATH
 PM
 PM
 Yes
 Therapeutic Complication
 Could not be determined
 Mil.
 Mil.
 No
 Other (Specify)
______________________________
PLACE OF INJURY
TRANSPORTATION INJURY
 Driver/Operator  Passenger  Pedestrian  Not Applicable
 Other (Specify) __________________________________
LOCATION/ADDRESS OF INJURY
M.E. DATE PRONOUNCED (Month DD, YYYY)
 AM  PM  Military
DESCRIBE HOW INJURY OCCURRED
M.E. TIME PRONOUNCED
IF FEMALE, PREGNANCY STATUS AT TIME OF DEATH
DID TOBACCO USE CONTRIBUTE TO DEATH?
 Not pregnant within the past year  Pregnant at time of death  Not pregnant, but pregnant within 42 days of
 Yes
 No
death  Not pregnant, but pregnant within 43 days to 1 year before death  Unknown, if pregnant in past year
 Probably  Unknown
MEDICAL CERTIFIER INFORMATION – NAME/TITLE
 AM  PM
HOUR OF DEATH
 Military
MEDICAL CERTIFIER INFORMATION – ADDRESS
LICENSE #
MEDICAL CERTIFIER DESIGNATION
 Certifier in attendance at time of death  Physician in charge of patient’s care  Nurse Practitioner in attendance at time of death
 Nurse Practitioner in charge of patient’s care
 Medical Examiner
MEDICAL CERTIFIER FAX NUMBER TO
MEDICAL CERTIFIER TELEPHONE NUMBER
RECEIVE ATTESTATION FORM
PROVIDER IN CHARGE OF PATIENT’S CARE – NAME/TITLE
 R.N.  P.A.  N.P.
 AM
RN/ PA/ NP
IF YES, DATE (Month DD, YYYY)
IF YES,
PRONOUNCER INFORMATION – NAME
TITLE
PRONOUNCEMENT?
TIME
Mil.
 PM
 Yes
 No
DATE SIGNED (Month DD, YYYY)
On the basis of examination and/or investigation in my opinion death occurred at the time, date, and place and due to the
cause(s) stated
.
Signature and Title of Medical
Certifier Required.