DRAFT CERTIFICATE FOR CONSULTATION

CORONERS AND JUSTICE ACT 2009

COUNTERFOIL AP 000000 S Attending Practitioner’s Certificate prescribed by the Death Certification Regulations XXXX AP 000000 S
For use by the person completing the certificate. MEDICAL CERTIFICATE OF CAUSE OF DEATH Date of Medical
For use only by a Registered Medical Practitioner who is qualified to do so in accordance with regulation 2(2) of the Death Certification Regulations XXXX.
Name of deceased person The certificate may only be given to a registrar after the certified cause has been confirmed by a duly appointed medical examiner and Examiner’s Confirmation
Joile M Mundu Shabani the date of this confirmation is shown on the certificate. This certificate is not required for any death that is investigated by a coroner.
24 0 7 2023
Gender F Joile Mantezolo Mundu Shabani F
Name of deceased person .......................................................................... Gender ........... NHS No. 4 5 0 5 5 7 1 7 0 4 Registrar to enter
NHS No. 4 5 0 5 5 7 1 7 0 4

.
Date of death as stated to me 0 1 0 8 2 0 2 3 Date last seen alive by me 0 1 0 8 2 0 2 3 Age as stated to me ...... No. of Death Entry
Date of death 01 0 8 2023 26

.
Date last seen
The Haven Healthcare Ltd
Place of death ..........................................................................................................................................................................
01 0 8 2023

.
alive by me

} }
1 The certified cause of death takes account of information obtained from post-mortem. a Externally examined after death by me.
Please ring
Age 38 2 Information from post-mortem may be available later. appropriate b Externally examined after death on my behalf by:
digit(s) and Mr Mabel Arasomwan
Place of death The Haven 3 Post-mortem not being held.
letter Name .............................................. GMC No. 7 6 3 1 4 9 0

.
4 I may later be able to supply additional information for statistical purposes. c Not examined after death by me or on my behalf.
Healthcare Ltd

Post-mortem/
SPACE FOR BINDING

additional information* 1 2 3 4 CAUSE OF DEATH Approximate interval

between onset and death
The condition thought to be the ‘Underlying Cause of Death’ should appear in the lowest completed line of Part I.
Externally examined
after death* a b c Cardiac arrest
I (a) Disease or condition directly leading to death* .................................................................................................................................................................. Asystole on ECG
........................................

.
.
If b, name Mr Mabel Arasomwan
High blood pressure (hypertension)
(b) Other disease or condition, if any, leading to I(a) .............................................................................................................................................................. Echocardiography
........................................
and GMC No. 7 6 3 1 4 9 0

.
This is the causal chain of events that ultimately leads to death.
(c) Other disease or condition, if any, leading to I(b) .............................................................................................................................................................. Systemic lupus
........................................
Cause of death:

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.
I (a) Cardiac arrest (d) Other disease or condition, if any, leading to I(c) .............................................................................................................................................................. pulmonary disease
........................................

.
.
(b) High blood pressure (hypertension)
II Other significant conditions CONTRIBUTING TO THE DEATH ............................................................................................................................................. Anasarca
........................................
(c) This is the causal chain of

.
.
(d) events that ultimately but not related to the disease or condition causing it ............................................................................................................................................................. Erythematosus
........................................
.
.
*This means the disease or condition that caused death (if an injury or complication, authorised by a coroner); do not record terminal events (e.g. cardiac or respiratory arrest, shock) as the only cause of death.
II leads to death
For a woman, was the deceased pregnant or recently pregnant? □ Yes □ ✔
No □ Unknown

Did the pregnancy contribute to At time of death Within 42 days before the death
the death? Between 43 days up to 1 year before death ✔
Unknown

Yes No ✔ Unknown Did the pregnancy contribute to the death? no Yes ✔

No Unknown

Name (print)
I hereby certify that I attended the deceased in accordance with the Death John shabani Mundu
Name (print) ....................................................................................... GMC No. 5 4 2 2 1 0 9
John shabani Mundu Certification Regulations xxxx and that the particulars and cause of death
.
given on this certificate are true to the best of my knowledge and belief
GMC No. 5 4 2 2 1 0 9 Signature .................................................................................................... Date 01 0 8 2023
.
*Ring appropriate digit(s) and letter
For deaths in hospital: please give the name of the consultant responsible for the above named as a patient Dr Uchenna Chibueze Nwosu
 DRAFT CERTIFICATE FOR CONSULTATION

Fold here
MEDICAL CERTIFICATE OF CAUSE OF DEATH What will the registrar ask?
The person who registers the death will be asked to provide the following
What is this form? information about the deceased.
This form shows the cause of death that has been certified by an attending 1. Full forename and family name (and maiden name if applicable)
doctor and confirmed by an independent medical examiner. It has been given
to you so that you can use it to arrange for the death to be registered. 2. Date and place of birth
You must only be given this form after a medical examiner has confirmed the 3. Date and place of death
cause and the date of confirmation has been written on the front of the form
by, or on behalf of, the attending doctor. 4. Usual address

Before confirming the cause of death, the medical examiner, or someone 5. Occupation
acting on behalf of the medical examiner, will have spoken with you, or with 6. Whether the deceased was in receipt of a pension or allowance from public
another person who is qualified to register the death, to answer questions


funds
about the cause and to allow any concerns to be raised that might require the
medical examiner to make further enquiries or the death to be investigated by 7. If applicable – the name, date of birth and occupation of any surviving spouse


a coroner. or civil partner

Who can register the death? Requirements for registration

One of the people listed below should register the death within five days of the A registrar can only register the death and/or provide a certificate for burial,
date on which the cause was certified by the medical examiner (see date given cremation or other means of disposal after:
overleaf).

SPACE FOR BINDING

• This certificate has been taken to the register office and a medical examiner
This list is given in order of preference. has notified the registrar of the confirmed cause of death shown on the
certificate.
• Any relative or partner of the deceased who has knowledge of the information

required for registration, or • A person who is able to register the death has provided a signature
to confirm that the cause of death has been discussed with a medical
• any personal representative of the deceased, or examiner.
• a person present at the death, or It would be helpful if the person with whom the medical examiner discussed
• an occupant of the house, or an official from the hospital, or the person the cause of death could either register the death or attend the register office
with the person who will register the death. If this is not possible, the person

arranging the burial or cremation, or, if the death did not occur in a house or
hospital, the person who found or took charge of the body. who registers the death should be told about the discussion with the medical
examiner so that s/he can provide the signature mentioned above.

Where to register the death If the person who registers the death raises any concerns that have not been
discussed with a medical examiner, the registrar will need to speak with the
The form should be taken to the register office shown below. Most register
medical examiner or refer the death to a coroner.
offices ask you to telephone to make an appointment so that a registrar is
available when you visit. If you are unable to arrange for an appropriate person
to register the death within five days, please call the registrar for advice. After registration
Once the death has been registered, the registrar will keep this form and will
give you a Death Certificate, which is usually required to settle the deceased
person’s estate.
The registrar will also provide a certificate for burial, cremation or other
means of disposal. This certificate will need to be given to the cemetery,
Note to issuer: Please attach a label with the address and telephone
crematorium or a funeral director, if used, with an appropriate application
number of the register office in the district where the death occurred.
and, for cremations, with evidence that any implants or medical devices have
been removed.