1. Texas Death Registration: Roles & Responsibilities
2012 VSU Regional Conferences
Tara Carmean & Victor Farinelli

2. A brief overview of the U.S. Death Registration System
History

3. The US Vital Registration System is unique
In some ways the American system is unique…
Our death registration process (and vital registration process in general) is not a federal function. This is different from many other countries. When our forefathers wrote the Constitution the census was included as a national function, but not vital registration. This means that our vital registration process began as a local and then a state function. It also means that initially, vital registration was done differently in different communities and states.
The US Vital Registration System is unique
Unlike the Census, Vital Registration functions not included in Constitution
Vital Registration began as a local and then a State function

4. The first U.S. death records recorded in the 1600’s
Original vital registration laws (Virginia in 1632) were for the protection of individual rights.
used as statements of fact essential to protect individual rights, especially and distribution of property.
Initially, little or no statistical use was made
No indication that they were used for health purposes.
The first U.S. death records recorded in the 1600’s
Used for property rights and distribution of property

5. Industrialization and rapid urbanization
The 19th century was a time of industrialization and rapid urbanization. This created:
overcrowding in cities
sanitary issues and polluted water
poverty
catastrophic epidemics of typhus, yellow fever and cholera. .
Large cities started to create local health or sanitary boards, usually in response to an acute epidemic
This is when Health officers started scanning the burial returns or weekly list of interments and roughly compiling them in statistical reports.
Using death records to identify and combat epidemics and as a means of reporting health conditions.
Used information to deal with sanitary conditions, epidemics, and diseases
In response, the medical and science community also started to encourage vital registration and vital statistics in an effort to deal with public health. They recognized the important information that could be collected from vital records for public health purposes
In 1846, The American Medical Association created a committee to consider methods for improving death registration (and vital registration overall).
Promoted the use of mortality statistics in the study of health conditions of the US population.
Recommendations sent to State legislatures on the need for registration laws.
As the need for vital statistics grew, it became more apparent that a national system of vital statistics was needed
Industrialization and rapid urbanization
Overcrowding and poverty
Polluted water and sanitary issues
Major epidemics

6. The Census Bureau Division of Vital Statistics, between 1910-1930
Up until 1902, Vital registration practices were being developed at a local and state level
The federal government was not collecting death statistics (or birth)
States collecting different data and had different registration processes
So in 1902, a permanent Bureau of the Census was established, and included a requirement to collect vital statistics from cities and states…. And the Division of Vital Statistics was born!
Only published vital statistics and vaguely coordinated practices in independent state offices.
They did not have responsibility over the vital registration system.
Initially , the first fundamental task of the Vital Statistics group was to get all states to join the national registration for births and deaths.
Problem: most states didn’t have a system that could be compared easily state to state or nationwide.
This meant that the death statistics that were collected from one state couldn’t be compared to other states because different information was being collected. And when you can’t compare the data, it makes it difficult to get a clear picture about the national public health.
In 1902, a national Division of Vital statistics was established
No authority over vital registration system
First task was getting states to join the national registration of deaths (and births too!)

7. There were huge problems associated with more people needing vital records during the depression and World War II because they needed birth and death certificates as proof of citizenship, paternity and to access government benefits, pensions, and services. States were burdened and many noticed that higher standards of performance were needed.
The Federal Government responded and in 1942, was the first time a federal agency was charged with responsibility over the national vital registration system
to coordinate a cooperative vital records system through a single national agency
preserving the responsibility of the States and local governments
promoting higher standards of performance
Collect data for US health statistics
In 1987, the responsibility was then transferred to the Centers of Disease Control and Prevention, the National Center for Health Statistics
currently still the national coordinating authority
In 1942, the 1st federal agency (the US Public Health Services) was charged with responsibility over vital registration
Coordinating a cooperative vital records system but preserving state responsibilities
In 1987, transferred to the CDC National Center for Health Statistics (NCHS)

8. More about the document you’re responsible for
The Death Certificate

9. An Important Record! Permanent legal record Needed by family
Fact of death
Needed by family
Used for medical and health related research efforts
Why it’s important to have a permanent legal record of the fact of death?
Fraud! More cases of fraud, so many government agencies and other companies require death cert for benefits, etc.
Can be introduced in court as evidence when a question about the death arises
How do families use death records?
Families need to settle claims, gain benefits, change over names for property, etc
Also application for insurance benefits, settlement of pensions claims and transfer of real and personal property
How are death records used statistically?
Health Departments could not perform their duties w/out data. Data is foundation on which to base effective public health programs! (From CDC book)
Identify public health problems
Measure results of programs established to alleviate these problems
Mortality Statistics are important to individual physicians and medical science
Used to identify disease etiologies and evaluate diagnostic techniques.
Demographers use mortality statistics in combination with natality statist to estimate and project population sizes, which are important in forecasting and program planning

10. The US Standard Certificate of Death
The TEXAS Death Certificate is adopted from the US Standard Certificate of Death, recommended by the National Center for Health Statistics (the federal agency with authority over the states that I just talked about)
Why is it important to have a standard death certificate? Or why is it important that States have similar death certificates?
The standard death certificate represents the minimum basic data set necessary for the collection and publication of comparable national, State and local vital statistics data.
The standard certificates have been the principal means for achieving the uniformity in information on which national vital statistics are based. - part of this cooperative effort.
The U.S. Standard certificates and reports are used as models for the development of State death certificates and forms.
States do not adopt all the US standard certificates and reports exactly as they are recommended but they are generally employed with only minor changes, still promoting a high degree of uniformity and comparability among the states.
The development/revisions of the standard certificates is a cooperative effort between federal and local partners
The revision process is designed to ensure that the standard certificates meet the uses for which they are intended, not only at the national level but also at the state and local levels.
Opinions are solicited from persons involved in preparation, registration, and processing of the records.
Opinions are also solicited from consumers of the data to determine whether changes need to be made and , if so, where.
Has anyone been registering death certificates long enough to have seen any changes or revisions to the death certificate?
D/c’s are revised approximately every 10 + years.
The first standard d/c was developed in 1900 by the US bureau of the Census.
Since that time there have been 10 revisions.
Can anyone guess why the death certificate is revised periodically?
To reflect changing social conditions and user demands for data.
The US Standard Certificate of Death
A total of 10 revisions, to date
Revision process involves persons involved in preparation, registration and processing of the records, and consumers of data

11. Electronic Death Registration System
Our d/c’s are no longer a paper process. Deaths are now being registered using across the United States using Electronic Death Registration Systems.
EDR recommended by the NCHS, NAPHSIS, and the SSA
SSA has provided funding since 1999 to support development of EDR systems throughout the U.S.
States has their own system
In Texas, our system is the Texas Electronic Registrar.
As of Nov, 2011 the number of states with EDR:
Up and Running (37)
In Development (4)
Planning/Requirements Stage (9)
There were also some long-standing issues with paper death certificates:
Certificates were not appropriately filed, may contain incorrect or inconsistent entries, or are not finalized until weeks after death
Late-filed, partially completed or inaccurate death certificates not acceptable for use by family members , nor do they meet federal administrative needs or satisfy the info demands of local, state and federal agencies.
Late or incomplete death certificates can adversely affect mortality statistics
Benefits of EDR
Greater efficiency- participants interact electronically
Improved timeliness of death registration
Higher quality data via real-time edits
Reduces errors in and rejection of death certificates
Promotes uniformity in demographic and cause-of-death statistics
Increased security and fraud prevention
Supports partial electronic/paper death registration
Capability to report fact-of-death to SSA with increased accuracy and timeliness
Verified Social Security numbers
Capability to report cause-of-death with increased accuracy and timeliness
Integral part of patient care
Uniformity in cause-of-death statistics
Improves the cause-of-death data for electronic disease surveillance systems
Electronic Death Registration System
Promoted improve data quality, timeliness and real-time linkage capabilities
Recommended by partnership between NCHS, NAPHSIS, and the SSA

12. Texas Electronic Registrar (TER)
Everyone should use TER:
The person in charge of interment or removal of a body HSC
The person completing the medical certification
HSC (h)
The State Registrar has supervisory power of local registrars to ensure uniform compliance
HSC
TER is the Electronic system specified by the State Registrar and was first implemented in 2007.
In order to be a fully collaborative process, each party should be using TER to file the death certificate.
Funeral Directors and Medical Certifiers are required by law
The State registrar has specified that death certificates should be filed using TER
Local Registrars should ensure the uniform compliance with vital statistics law
To ensure that other parties who are required by law can comply with the law
Per the State Registrar, who has supervisory power over local registrars and deputy registrars
Texas Health & Safety Code
PERSON REQUIRED TO FILE. The person in charge of interment or in charge of removal of a body from a registration district for disposition shall:
(1)  obtain and file the death certificate or fetal death certificate;
(2)  enter on the certificate the information relating to disposition of the body;
(3)  sign the certificate; and
(4)  file the certificate electronically as specified by the state registrar.
Texas Health & Safety Code Sec  (h)  
PERSONAL INFORMATION
(h)  The person completing the medical certification shall submit the information and attest to its validity using an electronic process approved by the state registrar.
Texas Health & Safety Code Sec  (a)
SUPERVISION AND INVESTIGATION BY STATE REGISTRAR
(a) The state registrar shall execute this title throughout the state. To ensure uniform compliance with this title, the state registrar has supervisory power over local registrars, deputy registrars, and subregistrars.

13. Selected responsible for filing a death certificate
partners

14. A Collaborative Process
Death Registration is a collaborative process between a Funeral Director, Medical Certifier, or Local Registrar.
Local Registrar
Funeral Director
Medical Certifier

15. Funeral Directors In Texas, approximately: 5000 Funeral Directors
1500 establishments
(Per TFSC, 2012)

16. Funeral Director Responsibilities
Send Report of Death within 24 hours
TAC 181.2
Obtain personal info from qualified person
HSC

17. More Funeral Director Responsibilities
Assign a Medical Certifier
Notify JP or ME office when appropriate
Demographically certify the record
Release the record to the Local Registrar

18. Time Requirements
24 hours – A Report of Death must be filed with the Local Registrar within 24 hours of taking custody of the body.
TAC (a)
10 Days – Death certificates must be filed within 10 day from the date of death.
HSC (a)
24 hours report of death REMINDER: from the time they take responsibility of the body

19. Medical Certifiers May Include: Physicians Primary Care Physicians
ER Doctors
Hospice Doctors
VA Doctors
Other specialties
Medical Examiners
12 ME’s offices in TX
Justices of the Peace

20. Medical Examiners & Justices of the Peace
Medical Certifiers
Physicians
Medical Examiners & Justices of the Peace
Can certify natural deaths in persons above six years of age
Must certify any death occurring by any means other than natural causes
The circumstances of a death determine who may certify the cause and manner of death.
If the death is anything other than natural, the Medical Examiner or Justice of Peace must certify the death.
If the death is natural, the attending physician may be the personal care physician – might be the best source of info regarding cause of death because they may have knowledge of pre-existing medical conditions. The personal physician may certify the death to the best of their knowledge even if they didn’t pronounce the death.
If the death is anything other than natural, an ME or JP needs to certify the death- may need an investigation or inquest. Examples:
Body found and cause unknown
Accident, suicide or homicide
Occurred without medical attendance
Physician is unable or unwilling to certify
Deceased is under 6 years

21. Medical Certifier Responsibilities
Verifying the date of death
Enter the Cause of Death
This represents the best medical opinion
Medically certify the record
Certify within 5 days of receiving notification.
HSC (b)
Complete Medical Amendments, as needed
DATE OF DEATH
The medical certifier is responsible for verifying the date of death
CAUSE OF DEATH
The most important statistical research item on the d/c
CERTIFY THE RECORD
Within 5 days of notification
Even if “pending”
COMPLETE MEDICAL AMENDMENTS
Needed to change the cause and manner of death, such as “pending investigation”
Must be completed and submitted only by the attending physician, JP or me that originally certified the death. Exception, if an inquest was conducted by a medical examiner or jp, the person conducting the inquest may sign the medical amendment if the death was originally certified by a physician.

22. Time Requirements!
5 Days – The Medical Certifier must complete the medical certification within 5 days after being designated.
HSC (b)
5 days from notification
This includes if the COD is pending. If pending, the MC will need to go back and complete an amendment once the COD is known.

23. Local Registrar In Texas: 254 Counties 445 Local Registration Offices
Local Registrars include:
Justice of the Peace
County & District Clerk
Municipal Clerks
City Clerks

24. Local Registrar Responsibilities
Secure a complete record for each death
HHS (a)
Review each record for completion
HHS (a)
Record the certificate and release to State
Issue Burial Transit Permits, as needed
SECURE A COMPLETE RECORD
LRs are mandated by law to ensure that all vital records in their registration district are filed.
REVIEW EACH RECORD
The law states “the local registrar shall carefully examine each birth or death certificate when presented for registration to determine if it is completed as required by this title and by the state registrar’s instructions. (b) if a death certificate is incomplete or unsatisfactory, the local registrar shall call attention to the defects in the return”.
It’s important to make sure the d/c is as complete and accurate as possible before it is filed to reduce errors and amendments.
RECORD & RELEASE
Texas is a dual registration state, which means that death records are filed both locally and with the state. Local registrars are responsible for ensuring that the records in their district are filed and completed appropriately.
BURIAL TRANSIT PERMITS
Required to ship or transport a body out of the state or to transport a body within the state. Also needed for cremation
A local registrar shall not issue a BTP until the cert of death is completed in so far as possible.- all the info related to the deceased is complete, and knowing that the record will be medically certified and filed

25. Time Requirements
10 Days – Death certificates must be filed within 10 day from the date of death.
HSC (a)

26. TX Vital Statistics Unit (VSU)
General Duties
Oversees vital registration in TX
Provides instructions and forms
Files and processes records
Preserves records
Issue records
Death Registration Specific Duties
Issues Disinternment Permits
Demographic Amendments
Formerly called BVS (Bureau of Vital Statistics), but our name changed to the Vital Statistics Unit when we became a part of DSHS.

27. Disinternment Permits
Serves as authority to disinter, transport and reinter a body within this state
Funeral Director or embalmer initiates application (VS-271), & consent form (VS-271.1)
Need signed consent from cemetery, owner of plot, and deceased’s next-of-kin
State Registrar issues in four parts
Copies retained by funeral director, sexton of the cemetery, the local registrar, and the State Registrar
Disinterment Permit (VS-2219)
The Disinterment Permit issued by VSU serves as the authority to disinter, transport, and reinter a body within this state. If the body is to be removed from the state, transported by common carrier within the state, or cremated, a Burial-Transit Permit must also be obtained. [HSC , HSC , 25 TAC 181.6]
A Disinterment Permit shall not be required if a body is to be disinterred and reinterred in the same cemetery.
The Application for a Disinterment Permit (VS-271) (39K .doc), must be signed by the funeral director or embalmer licensed by the Texas Funeral Commission making application for the permit. The sole responsibility for obtaining the consent of the cemetery, the owner of the plot, and the deceased's next-of-kin rests with the funeral director or embalmer making application for a Disinterment Permit. The application, consent forms, and $25.00 required fee must be sent to VSU.
The State Registrar issues the Disinterment Permit in four parts. The funeral director to whom the permit is issued shall retain a copy, a copy is to be filed by the sexton of the cemetery in which the reinterment is to be made, a copy shall be filed by the local registrar with the local registrar's copy of the Certificate of Death, and a copy will be filed by the State Registrar with the original Certificate of Death.
A Disinterment Permit is good for one (1) year from the date of issuance.
Instructions for Completing the Application for a Disinterment Permit (VS-271) (39K .doc).
Please type or print except where signatures are required. Names may be typed beneath the signature for clarification.
Enter the full name of the deceased as it appears on the Certificate of Death.
Enter the exact date of death. This information is vital in locating and identifying the Certificate of Death.
Enter the city, county, and state of death.
Enter the place of interment. These items must be completed with the full name of the cemetery, plot number (section, block, lot, and space or niche), city, county, and state in which the deceased is buried. The state should always be Texas, as we cannot issue a Disinterment Permit for an out of state burial.
Enter the place the body is to be reinterred (Items a-d). These items must be completed with the full name of the cemetery, plot number (section, block, lot, and space or niche), city, county, and state where the body will be reburied.
Enter the funeral director's full name and state license number along with the full name, address, and telephone number of the funeral home.
Provide the date and signature of the funeral director submitting the application.
Instructions for Completing the Disinterment Consent Form (VS-271.1) (24K .doc).
Procedures for Completing the Cemetery Consent Form The first portion of the Cemetery Consent Form must be completed by the cemetery owner or keeper.
Enter the plot and block number where the body is buried.
Enter the full name of the plot owner(s).
The signature line should be completed by the cemetery owner or keeper.
Enter the date the form was signed.
Enter the title of the person signing for the cemetery.
Enter the full name of the cemetery where the body is buried.
Procedures for Completing the Plot Owner Consent Form The middle portion of the Plot Owner Consent Form should be completed by the owner of the plot where the body is buried.
Enter the complete name of the cemetery where the body is buried.
The signature line should be completed by the owner of the plot.
Enter the date signed, along with the address and telephone number of the plot owner.
Next-of-kin
The third portion of the form entitled Next-of-kin Consent Form must be completed by the next-of-kin in order of priority [HSC (a)]:
the decedent's surviving spouse;
the decedent's surviving adult children;
the decedent's surviving parents;
the decedent's adult siblings; or
the adult person in the next degree of kinship in the order named by law to inherit the estate of the decedent.
Please Note: A person listed above may consent to the removal only if there is no person in a priority listed before that person. [HSC (b)]
Procedures for Completing the Next-of-kin Consent Form:
Enter the relationship of the signer to the deceased.
Enter the full name of the cemetery where the body is to be reburied.
The signature line should be completed by the next-of-kin.
Enter the date signed.
If all the required consent signatures cannot be obtained, the remains may be removed by permission of the county court of the county in which the cemetery is located. [HSC (c)]

28. Other partners that rely on accurate and complete records

29. Department of State Health Services Center for Health Statistics (CHS)
Mission: the source for
timely, accurate and useful health information in TX.
Reports include:
Vital Statistics Annual Reports
CHS uses the statistical information from Texas Death Certificates for public health purposes
The DSHS Center for Health Statistics was established to provide a convenient access point for health-related data for Texas.
CHS’s objective is to be a source of information for assessment of community health and for public health planning.
Data is used to support research, grant applications and policy development and to provide rapid needs response to health emergencies.
We also offer technical assistance in the appropriate use of the data we provide, and in the development of innovative techniques for data dissemination. We support the development and application of consistent standards for privacy and statistical validity.
CHS Mission: The Center for Health Statistics is THE SOURCE for timely, accurate and useful Health Information in Texas. We do this by:
Coordinating, integrating, and providing access, Adopting standards for collection and dissemination, Providing guidance and education, and Conducting analysis and interpretation,
while protecting the privacy of the citizens of Texas.
One of their reports include:
Vital Statistics Annual Reports
The vital statistics annual reports include data most frequently requested by users of Texas vital statistics.

30. National Center for Health Statistics (NCHS)
The principal health statistics agency in the US!
NCHS is required by law to:
Collect state data annually
Provide assistance in achieving comparability of data
Public Health Service Act, 42 USC 242k
Data collected through the
Nation Vital Statistics System (NVSS)
The CDC's National Center for Health Statistics (NCHS) is the nation's principal health statistics agency, providing data to identify and address health issues.
The law requires NCHS to collect data annually from states and provide assistance in achieving comparability of data (Public Health Service Act, 42 USC 242k)
The standard certificates are an important part of the vital statistics program through which NCHS obtains the data to produce national vital statistics data. This program is an endeavor of NCHS to cooperate with the states to improve the quality, timeliness, and utility of health data.
NCHS Data Sources include statistical information from death certificates
NCHS compiles statistical information to help guide public health and health policy decisions. These health statistics allow us to:
Document the health status of the U.S. population and selected subgroups.
Track impact of major policy initiatives including the Affordable Care Act.
Identify disparities in health status and use of health care by race/ethnicity, socio-economic status, region, and other population characteristics.
Document access to and use of the health care system.
Monitor trends in health status.
Support biomedical and health services research.
Provide data to support public policies and programs.

31. Resources VSU website: www.texasvsu.org
VSU Handbook on Death Registration:
DSHS Center for Health Statistics (CHS):
National Center for Health Statistics (NCHS):