[Department of Commerce / Bureau of the Census] [Standard Certificate of Death / State of Olkahoma] 
[State File No.] [Registrar's No.]

[1 Place of Death: (a) County] [(b) City or town] [(c) Name of hospital or institution:] 
[(d) Length of stay: in hostpial or insutitution] [In this community]

[2 Usual residence of decesased: (a) State] [(b) County] [(c) City or town] [(d) Street No.] 
[(e) Citizen of foreigh country?]

[3 (a) Full Name] [3(b) If veteran, name war] [3(c) Social Security No.] 

[4 Sex] [5 Color or rate] [6(a) Single, widowed, married, divorced] [6(b) NAme of husband or wife] 
[6(c) Age of husband or wife, if alive] [7 Birth date of deceased] [8 Age: Years] [Months] [Days] [Hr.] [Min.]

[9 Birthplace] [10] Usual occupation] [11 Industry or business]

[Father: 12 Name] [13 Birthplace]

[Mother: 14 Maiden name] [15 Birthplace]

[16(a) Informant's own signature] (signed) [(b) Address]

[17(a) Burial, cremation, or removal] [(b) Date thereof] [(c) Place] [Was body embalmed?] 
[Signature of empalmer] (signed) [18(a) Signature of funeral director] (signed) [(b) Address]

[19(a) Date received local registrat] [(b) Registrar's signature] (signed)

[Medical Certification: 20. Date of death: Month] [day] [year][hour] [minute] 

[21 I hereby certify that I attended the deceased from ] [19] [, to] [, 19 ] 
[; and that the death occurred on th edate and hour stated above.] 
[Immediate cause of death] [Due to] [Due to] [Other conditions] [Major findings: of operations] [of autopsy] 

[22 If death was due to external causes, fill in the following: (a) Accident, suicide, or homocide] 
[Date of occurrence] [(c) Where did injury occur?] [Did injury occur in or about home, on farm, in 
industrial place, in publica place? While at work?] [(e) Means of injury]

[23 Signature] [MD or other] [Address] [Date signed]