The two essential elements of the death certificate are the cause of death and the manner of death. If there is a delay between the onset of the disease and the death, the proximate and immediate causes of death need to be distinguished. The immediate cause is the disease or the injury that causes the death of a person at a particular time and place. The proximate cause is the disease or injury that initiates the series of events that eventually leads to death. The two may be the same, but this is not always so. For example, a person may suffer a myocardial infarct due to arteriosclerosis. The immediate cause of death is the infarct, the proximate cause of death is arteriosclerosis, and the manner of death is natural. The initiating event is the most important factor in determining the cause of death.

A concept that is often misunderstood by physicians is the mechanism or the mode of death, such as ventricular fibrilation, cardiac arrest, pulmonary arrest, etc. The Office of Vital Statistics requests that these mechanisms of death not be entered as causes of death on the death certificate. Ventricular fibrilation is likely a cause of arteriosclerotic heart disease or acute myocardial infarct. The mechanism of death should not be confused with the cause of death.

Florida law states that attending physicians are only permited to sign death certificates when the manner of death is natural. Treating physicians should be acquainted with Florida Statute 406, The Medical Examiner's Law. Section 406.11 "Examinations, Investigations and Autopsies" lists the types of deaths that fall under the Medical Examiner's jurisdiction. It is also the responsibility of any person who becomes aware of a death under any of the circumstances described in F.S. 406.11 to report such deaths and circumstances to the Medical Examiner. Once a doctor has determined that the death of his patient does not fit into any of the categories in F.S. 406, they have a duty to complete the death certificate if their patient had a disease process that may very well cause death.

Physicians who come to Florida from other states often site the "24-hour rule" as the reason for reporting a death to the Medical Examiner. Florida does not have such a rule, as do other states. A patient who dies less than 24 hours following admission to the hospital is not automatically considered a Medical Examiner's case, unless they meet other criteria outlined in F.S. 406.

Often, physicians that are on vacation or are not on-call for the weekend, leave other physicians to care for their patients. If one of these patients die, covering physicians are often reluctant to sign the death certificate. However, physicians must understand that it is their responsibility and their legal duty to certify the deaths of patients presently under their care, pursuant to F.S. 382.008. Physicians who assume call for their colleagues, assume the responsibility to take care of living patients and to certify the deaths of those patients that die. This may be done by carefully examining the decedent's medical records, just as the physician would do before treating any patient that becomes ill. The Medical Examiner does NOT exist to sign death certificates for vacationing doctors. Section 22d. of the death certificate is the space provided for a certifying physician to sign their name if they are not the decedent's regular attending doctor.

A death certificate is a very important document for families, funeral directors, the State's Vital Statistics Office and the medico-legal community. The doctor should phrase the cause of death carefully, write neatly and legibly, or preferably, type the entry and always avoid abbreviations. The death certificate is a statistical tool that should be easier to complete than the day to day diagnoses that is the responsibility of physicians. The cause of death is best explained as a probability and the death certificate does not have to be completed with 100% certitude in all cases. For example, it is acceptable to list the cause of death as "Probable Arteriosclerotic Heart Disease" in a patient who has an elevated cholesterol and whose wife advised you that he was clutching his chest and complaining of chest pain. However, if the physician has a reasonable doubt about the manner of death or has concerns as to how to properly certify a death, we encourage the physician to contact the Medical Examiner for help and advise.