SIGNATURE � |
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42. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 28) |
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43. TITLE OF CERTIFIER |
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44. CERTIFIER MO LICENSE NUMBER |
45. CERTIFIER NPI NUMBER |
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46. DATE CERTIFIED (Month, Day, Year) |
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47. REGISTRARʼS SIGNATURE |
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48. FOR REGISTRAR ONLY - DATE FILED (Month, Day, Year) |
� |
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49. DECEDENTʼS EDUCATION |
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50. DECEDENT OF HISPANIC ORIGIN? |
51. DECEDENTʼS RACE |
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(Check the box that best describes the highest degree or level of school |
(Check the box that best describes whether the |
(Check one or more races to indicate what the decedent considered himself or herself to be.) |
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completed at time of death.) |
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decedent is Spanish/Hispanic/Latino. Check the |
White |
Other Asian |
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“No” box if decedent is not Spanish/Hispanic/Latino.) |
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8th grade or less |
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Black or African American |
(Specify) __________________________ |
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No, not Spanish/Hispanic/Latino |
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9th - 12th grade; no diploma |
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American Indian or Alaska Native |
Native Hawaiian |
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Yes, Mexican, Mexican American, |
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High school graduate or GED completed |
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(Name of the enrolled or principal tribe) |
Guamanian or Chamorro |
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Chicano |
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Some college credit, but no degree |
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____________________________ |
Samoan |
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Yes, Puerto Rican |
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Associate degree (e.g., AA, AS) |
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Asian Indian |
Other Pacific Islander |
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Yes, Cuban |
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Bachelorʼs degree (e.g., BA, AB, BS) |
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Chinese |
(Specify) __________________________ |
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Yes, other Spanish/Hispanic/Latino |
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Masterʼs degree (e.g., MA, MS, MEng, MeD, MSW, MBA) |
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Filipino |
Other |
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(Specify) ________________________ |
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Doctorate (e.g., PhD, EdD) or professional |
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Japanese |
(Specify) __________________________ |
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degree (e.g., MD, DDS, DVM, LLB, JD) |
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Korean |
Unknown |
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Vietnamese |
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52. DECEDENTʼS USUAL OCCUPATION (INDICATE TYPE OF WORK DONE DURING MOST OF WORKING LIFE. DO NOT USE |
53. KIND OF BUSINESS/INDUSTRY |
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52. “RETIRED”.) |
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EMBALMED |
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NOT EMBALMED |
STATEMENT BY LICENSED EMBALMER |
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I hereby certify that the deceased named above was embalmed by me, ________________________________________________________________________________________
or by student _________________________________________________________________ on __________________________________ working under my personal supervision.