Vital Statistics Reference Guidance Number 03, February, 2023

U.S. Department of Health and Human Services • Centers for Disease Control and Prevention • National Center for Health Statistics • National Vital Statistics System

Vital Statistics Reporting Guidance

Report No. 3 ▪ Released April 2020 – Expanded February 2023

Guidance for Certifying Deaths Due to

Coronavirus Disease 2019 (COVID-19)

Expanded in February 2023 to Include Guidance for Certifying Deaths Due to

Post-acute Sequelae of COVID-19

Introduction

In December 2019, an outbreak of a respiratory disease

associated with a novel coronavirus was reported in the city of

Wuhan in the Hubei province of the People's Republic of China

(1). The virus has spread worldwide and on March 11, 2020, the

World Health Organization declared Coronavirus Disease 2019

(COVID-19) a pandemic (2). The first case of COVID-19 in the

United States was reported in January 2020 (3) and the first death

in February 2020 (4), both in Washington State. Since then, the

number of reported cases in the United States has increased and

is expected to continue to rise (5).

In public health emergencies, mortality surveillance provides

crucial information about population-level disease progression,

as well as guides the development of public health interventions

and assessment of their impact. Monitoring and analysis of

mortality data allow dissemination of critical information to

the public and key stakeholders. One of the most important

methods of mortality surveillance is through monitoring causes

of death as reported on death certificates. Death certificates

are registered for every death occurring in the United States,

offering a complete picture of mortality nationwide. The death

certificate provides essential information about the deceased

and the cause(s) and circumstances of death. Appropriate

completion of death certificates yields accurate and reliable data

for use in epidemiologic analyses and public health reporting.

A notable example of the utility of death certificates for public

health surveillance is the ongoing monitoring of pneumonia and

influenza deaths. Accurate and timely death certificate data are

integral to detecting elevated levels of influenza activity in real

time (https://www.cdc.gov/flu/weekly/index.htm).

Monitoring the emergence of COVID-19 in the United States

and guiding public health response will also require accurate

and timely death reporting. The purpose of this report is to

provide guidance to death certifiers on proper cause-of-death

certification for cases where confirmed or suspected COVID-19

infection resulted in death. As clinical guidance on COVID-19

evolves, this guidance may be updated, if necessary. When

COVID-19 is determined to be a cause of death, it is important

that it be reported on the death certificate to assess accurately the

effects of this pandemic and appropriately direct public health

response.

Cause-of-Death Reporting

When reporting cause of death on a death certificate, use any

information available, such as medical history, medical records,

laboratory tests, an autopsy report, or other sources of relevant

information. Similar to many other diagnoses, a cause-of-death

statement is an informed medical opinion that should be based

on sound medical judgment drawn from clinical training and

experience, as well as knowledge of current disease states and

local trends (6).

Part I

This section on the death certificate is for reporting the sequence

of conditions that led directly to death. The immediate cause of

death, which is the disease or condition that directly preceded

death and is not necessarily the underlying cause of death

(UCOD), should be reported on line a. The conditions that led

to the immediate cause of death should be reported in a logical

sequence in terms of time and etiology below it.

The UCOD, which is “(a) the disease or injury which initiated

the train of morbid events leading directly to death or (b) the

circumstances of the accident or violence which produced the

fatal injury” (7), should be reported on the lowest line used in

Part I.

Approximate interval: Onset to death

For each condition reported in Part I, the time interval between

the presumed onset of the condition, not the diagnosis, and death

should be reported. It is acceptable to approximate the intervals

or use general terms, such as hours, days, weeks, or years.

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Part II

Other significant conditions that contributed to the death, but

are not a part of the sequence in Part I, should be reported in

Part II. Not all conditions present at the time of death have to

be reported—only those conditions that actually contributed to

death.

Certifying deaths due to COVID-19

If COVID-19 played a role in the death, this condition should be

specified on the death certificate. In many cases, it is likely that

it will be the UCOD, as it can lead to various life-threatening

conditions, such as pneumonia and acute respiratory distress

syndrome (ARDS). In these cases, COVID-19 should be reported

on the lowest line used in Part I with the other conditions to

which it gave rise listed on the lines above it.

Generally, it is best to avoid abbreviations and acronyms, but

COVID-19 is unambiguous, so it is acceptable to report on the

death certificate.

In some cases, survival from COVID-19 can be complicated by

pre-existing chronic conditions, especially those that result in

diminished lung capacity, such as chronic obstructive pulmonary

disease (COPD) or asthma. These medical conditions do not

cause COVID-19, but can increase the risk of contracting a

respiratory infection and death, so these conditions should be

reported in Part II and not in Part I.

When determining whether COVID-19 played a role in the

cause of death, follow the CDC clinical criteria for evaluating a

person under investigation for COVID-19 and, where possible,

conduct appropriate laboratory testing using guidance provided

by CDC or local health authorities. More information on

CDC recommendations for reporting, testing, and specimen

collection, including postmortem testing, is available from:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing.html

and https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-

postmortem-specimens.html. It is important to remember that

death certificate reporting may not meet mandatory reporting

requirements for reportable diseases; contact the local health

department regarding regulations specific to the jurisdiction.

In cases where a definite diagnosis of COVID-19 cannot be

made, but it is suspected or likely (e.g., the circumstances

are compelling within a reasonable degree of certainty), it

is acceptable to report COVID-19 on a death certificate as

“probable” or “presumed.” In these instances, certifiers should

use their best clinical judgement in determining if a COVID-19

infection was likely. However, please note that testing for

COVID-19 should be conducted whenever possible.

Common problems

Common problems in cause-of-death certification include:

1. reporting intermediate causes as the UCOD (i.e., on the

lowest line used in Part I),

2. lack of specificity, and

3. illogical sequences.

Intermediate causes are those conditions that typically have

multiple possible underlying etiologies and thus, a UCOD must

be specified on a line below in Part I. For example, pneumonia

is an intermediate cause of death since it can be caused by a

variety of infectious agents or by inhaling a liquid or chemical.

Pneumonia is important to report in a cause-of-death statement

but, generally, it is not the UCOD. The cause of pneumonia,

such as COVID-19, needs to be stated on the lowest line used

in Part I.

Additionally, the reported UCOD should be specific enough to

be useful for public health and research purposes. For example,

a “viral infection” can be a UCOD, but it is not specific. A more

specific UCOD in this instance could be “COVID-19.”

All causal sequences reported in Part I should be logical in terms

of time and pathology. For example, reporting “COVID-19” due

to “chronic obstructive pulmonary disease” in Part I would be an

illogical sequence as COPD cannot cause an infection, although

it may increase susceptibility to or exacerbate an infection. In

this instance, COVID-19 would be reported in Part I as the

UCOD and the COPD in Part II. While there can be reasonable

differences in medical opinion concerning a sequence that led

to a particular death, the causes should always be provided in a

logical sequence from the immediate cause on line a. back to the

UCOD on the lowest line used in Part I.

Certifying deaths due to post-acute sequelae of

COVID-19

In the acute phase, clinical manifestations and complications

of COVID-19 of varying degrees have been documented,

including death. However, patients who recover from the acute

phase of the infection can still suffer long-term effects (8).

Post-acute sequelae of COVID-19 (PASC), commonly referred

to as “long COVID,” refers to the long-term symptoms, signs,

and complications experienced by some patients who have

recovered from the acute phase of COVID-19 (8–10). Emerging

evidence suggests that severe acute respiratory syndrome

coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19,

can have lasting effects on nearly every organ and organ system

of the body weeks, months, and potentially years after infection

(11,12). Documented serious post-COVID-19 conditions include

cardiovascular, pulmonary, neurological, renal, endocrine,

hematological, and gastrointestinal complications (8), as well as

death (13).

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Consequently, when completing the death certificate, certifiers

should carefully review and consider the decedent’s medical

history and records, laboratory test results, and autopsy report,

if one is available. For decedents who had a previous SARS-

CoV-2 infection and were diagnosed with a post-COVID-19

condition, the certifier may consider the possibility that the death

was due to long-term complications of COVID-19, even if the

original infection occurred months or years before death. If it is

determined that PASC was the UCOD, it should be reported on

the lowest line used in Part I with the condition(s) it led to on the

line(s) above in a logical sequence in terms of time and etiology.

If it is determined that PASC was not the UCOD but was still a

significant condition that contributed to death, then it should be

reported in Part II. Certifiers should use standard terminology,

that is, “Post-acute sequelae of COVID-19.” See Scenario IV in

the Appendix for an example certification. In accordance with

all death certification guidance, if the certifier determines that

PASC did not cause or contribute to death, then they should not

report it anywhere on the death certificate.

Manner of death

The manner of death, sometimes referred to as circumstances of

death, is also reported on death certificates. Natural deaths are

due solely or almost entirely to disease or the aging process (14).

In the case of death due to a COVID-19 infection, the manner of

death will almost always be natural.

When to Refer to a Medical Examiner or

Coroner

Some jurisdictions have requirements for referring deaths

involving threats to public health to the medical examiner

or coroner, so certifiers should follow the regulations in the

jurisdiction in which the death occurred. As always, if a death

involved an injury, poisoning, or complications thereof, then the

case should be referred. The local medical examiner or coroner

should be consulted with questions on referral requirements.

Conclusion

An accurate count of the number of deaths due to COVID-19

infection, which depends in part on proper death certification,

is critical to ongoing public health surveillance and response.

When a death is due to COVID-19, it is likely the UCOD and

thus, it should be reported on the lowest line used in Part I of

the death certificate. Ideally, testing for COVID-19 should be

conducted, but it is acceptable to report COVID-19 on a death

certificate without this confirmation if the circumstances are

compelling within a reasonable degree of certainty.

For more guidance and training on cause-of-death reporting

in general, see the Cause of Death mobile app available

from: https://www.cdc.gov/nchs/nvss/mobile-app.htm and the

Improving Cause-of-Death Reporting online training module

available from: https://www.cdc.gov/nchs/nvss/improving-

cause-of-death-reporting.htm (free Continuing Medical

Education credits and Continuing Nursing Education credits

available). For current information on the COVID-19 outbreak,

see the CDC website at: https://www.cdc.gov/coronavirus/2019-

nCoV/index.html.

References

1. World Health Organization. Novel coronavirus—China.

Geneva, Switzerland. 2020. Available from: https://www.

who.int/emergencies/disease-outbreak-news/item/2020-

DON233.

2. World Health Organization. WHO Director-General’s

opening remarks at the media briefing on COVID-19—11

March 2020. Geneva, Switzerland. 2020. Available from:

https://www.who.int/dg/speeches/detail/who-director-

general-s-opening-remarks-at-the-media-briefing-on-

covid-19---11-march-2020.

3. Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman

J, Bruce H, et al. First case of 2019 novel coronavirus in

the United States. N Engl J Med. 382(10):929–36. 2020.

Available from: https://www.nejm.org/doi/full/10.1056/

NEJMoa2001191.

4. Centers for Disease Control and Prevention. CDC,

Washington state report first COVID-19 death [press

release]. 2020. Available from: https://www.cdc.gov/

media/releases/2020/s0229-COVID-19-first-death.html.

5. Centers for Disease Control and Prevention. CDC confirms

possible instance of community spread of COVID-19 in

U.S. [press release]. 2020. Available from: https://www.

cdc.gov/media/releases/2020/s0226-Covid-19-spread.

html.

6. National Center for Health Statistics. Physician’s handbook

on medical certification of death. Hyattsville, MD: National

Center for Health Statistics. 2003.

7. World Health Organization. International statistical

classification of diseases and related health problems, 10th

revision (ICD–10), Volume 2. 5th ed. Geneva, Switzerland.

2016.

8. Sanyaolu A, Marinkovic A, Prakash S, Zhao A, Balendra

V, Haider N, et al. Post-acute sequelae in COVID-19

survivors: An overview. SN Compr Clin Med 4(1):1–12.

2022.

Vital Statistics Reporting Guidance

U.S. Department of Health and Human Services • Centers for Disease Control and Prevention • National Center for Health Statistics • National Vital Statistics System

9. Yomogida K, Zhu S, Rubino F, Figueroa W, Balanji N,

Holman E. Post-acute sequelae of SARS-CoV-2 infection

among adults aged ≥ 18 Years—Long Beach, California,

April 1–December 10, 2020. MMWR Morb Mortal Wkly

Rep 70(37):1274–7. 2021.

10. Cabrera Martimbianco AL, Pacheco RL, Bagattini ÂM,

Riera R. Frequency, signs and symptoms, and criteria

adopted for long COVID-19: A systematic review. Int J

Clin Pract 75(10):e14357. 2021.

11. Stein SR, Ramelli SC, Grazioli A, Chung J-Y, Singh M,

Yinda CK, et al. SARS-CoV-2 infection and persistence

in the human body and brain at autopsy. Nature

612(7941):758–63. 2022.

12. National Institutes of Health. Long COVID. 2022.

Available from: https://covid19.nih.gov/covid-19-topics/

long-covid.

13. Ahmad FB, Anderson RN, Cisewski JA, Sutton PD.

Identification of deaths with post-acute sequelae of

COVID-19 from death certificate literal text: United States,

January 1, 2020–June 30, 2022. Vital Statistics Rapid

Release; no 25. Hyattsville, MD: National Center for

Health Statistics. December 2022. DOI: https://dx.doi.

org/10.15620/cdc:121968.

14. National Center for Health Statistics. Medical examiner’s

and coroner’s handbook on death registration and fetal

death reporting. Hyattsville, MD: National Center for

Health Statistics. 2003.

Vital Statistics Reporting Guidance

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Appendix. Scenarios and Example

Certifications for Deaths Due to COVID-19

Scenario I: A 77-year-old male with a history of

hypertension and chronic obstructive pulmonary

disease

A 77-year-old male with a 10-year history of hypertension and

chronic obstructive pulmonary disease (COPD) presented to a

local emergency department complaining of 4 days of fever,

cough, and increasing shortness of breath. He reported recent

exposure to a neighbor with flu-like symptoms. He stated that

his wheezing was not improving with his usual bronchodilator

therapy. Upon examination, he was febrile, hypoxic, and in

moderate respiratory distress. His chest x-ray demonstrated

hyperinflation and his arterial blood gas was consistent with

severe respiratory acidosis. Testing of respiratory specimens

indicated COVID-19. He was admitted to the ICU and despite

aggressive treatment, he developed worsening respiratory

acidosis and sustained a cardiac arrest on day 3 of admission.

Comment: In this case, the acute respiratory acidosis was

the immediate cause of death, so it was reported on line a.

Acute respiratory acidosis was precipitated by the COVID-19

infection, which was reported below it on line b. in Part I. The

COPD and hypertension were contributing causes but were not

a part of the causal sequence in Part I, so those conditions were

reported in Part II.

CAUSE OF DEATH (See instructions and examples)

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac

arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional

lines if necessary.

IMMEDIATE CAUSE (Final

disease or condition ---------> a._____________________________________________________________________________________________________________

resulting in death) Due to (or as a consequence of):

Sequentially list conditions, b._____________________________________________________________________________________________________________

if any, leading to the cause Due to (or as a consequence of):

listed on line a. Enter the

UNDERLYING CAUSE c._____________________________________________________________________________________________________________

(disease or injury that Due to (or as a consequence of):

initiated the events resulting

in death) LAST d._____________________________________________________________________________________________________________

Approximate

interval:

Onset to death

_____________

33. WAS AN AUTOPSY PERFORMED?

Yes No

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

34. WERE AUTOPSY FINDINGS AVAILABLE TO

COMPLETE THE CAUSE OF DEATH?

Yes No

35. DID TOBACCO USE CONTRIBUTE

TO DEATH?

Yes Probably

No Unknown

36. IF FEMALE:

Not pregnant within past year

Pregnant at time of death

Not pregnant, but pregnant within 42 days of death

Not pregnant, but pregnant 43 days to 1 year before death

Unknown if pregnant within the past year

37. MANNER OF DEATH

Natural Homicide

Accident Pending Investigation

Suicide Could not be determined

Acute respiratory acidosis 3 days

1 weekCOVID-19

Scenario I

Chronic obstructive pulmonary disease, hypertension

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Scenario II: A 34-year-old female with no significant

past medical history

A 34-year-old female with no significant past medical history

presented to her primary care physician complaining of 6 days

of fever, cough, and myalgias. She was found to be febrile,

hypotensive, and hypoxic. She was admitted to the hospital

and underwent a CT scan of the chest, which revealed diffuse

ground-glass opacification indicative of viral pneumonia.

Respiratory specimens were sent for testing and rRT-PCR

confirmed COVID-19. Her condition deteriorated over the next

2 days and she developed acute respiratory distress syndrome

(ARDS). She was transferred to the ICU and started on positive

pressure ventilation. Despite aggressive resuscitation, the patient

expired on hospital day 4.

Comment: In this case, the immediate cause of death was ARDS,

so it was reported on line a. as a consequence of pneumonia,

which was reported on line b. The underlying cause of death

(UCOD) was COVID-19 so it was reported on line c., the lowest

line used in Part I.

CAUSE OF DEATH (See instructions and examples)

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac

arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional

lines if necessary.

IMMEDIATE CAUSE (Final

disease or condition ---------> a._____________________________________________________________________________________________________________

resulting in death) Due to (or as a consequence of):

Sequentially list conditions, b._____________________________________________________________________________________________________________

if any, leading to the cause Due to (or as a consequence of):

listed on line a. Enter the

UNDERLYING CAUSE c._____________________________________________________________________________________________________________

(disease or injury that Due to (or as a consequence of):

initiated the events resulting

in death) LAST d._____________________________________________________________________________________________________________

Approximate

interval:

Onset to death

_____________

33. WAS AN AUTOPSY PERFORMED?

Yes No

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

34. WERE AUTOPSY FINDINGS AVAILABLE TO

COMPLETE THE CAUSE OF DEATH?

Yes No

35. DID TOBACCO USE CONTRIBUTE

TO DEATH?

Yes Probably

No Unknown

36. IF FEMALE:

Not pregnant within past year

Pregnant at time of death

Not pregnant, but pregnant within 42 days of death

Not pregnant, but pregnant 43 days to 1 year before death

Unknown if pregnant within the past year

37. MANNER OF DEATH

Natural Homicide

Accident Pending Investigation

Suicide Could not be determined

Acute respiratory distress syndrome 2 days

10 days

Pneumonia

COVID-19

Scenario II

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Scenario III: An 86-year-old female with an

unconfirmed case of COVID-19

An 86-year-old female passed away at home. Her husband

reported that she was nonambulatory after suffering an ischemic

stroke 3 years ago. He stated that 5 days prior, she developed a

high fever and severe cough after being exposed to an ill family

member who subsequently was diagnosed with COVID-19.

Despite his urging, she refused to go to the hospital, even when

her breathing became more labored and temperature escalated.

She was unresponsive that morning and her husband phoned

emergency medical services (EMS). Upon EMS arrival, the

patient was pulseless and apneic. Her husband stated that he

and his wife had advanced directives and that she was not to be

resuscitated. After consulting with medical command, she was

pronounced dead and the coroner was notified.

Comment: Although no testing was done, the coroner

determined that the likely UCOD was COVID-19 given the

patient’s symptoms and exposure to an infected individual.

Therefore, COVID-19 was reported on the lowest line used

in Part I. Her ischemic stroke was considered a factor that

contributed to her death but was not a part of the direct causal

sequence in Part I, so it was reported in Part II.

CAUSE OF DEATH (See instructions and examples)

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac

arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional

lines if necessary.

IMMEDIATE CAUSE (Final

disease or condition ---------> a._____________________________________________________________________________________________________________

resulting in death) Due to (or as a consequence of):

Sequentially list conditions, b._____________________________________________________________________________________________________________

if any, leading to the cause Due to (or as a consequence of):

listed on line a. Enter the

UNDERLYING CAUSE c._____________________________________________________________________________________________________________

(disease or injury that Due to (or as a consequence of):

initiated the events resulting

in death) LAST d._____________________________________________________________________________________________________________

Approximate

interval:

Onset to death

_____________

33. WAS AN AUTOPSY PERFORMED?

Yes No

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

34. WERE AUTOPSY FINDINGS AVAILABLE TO

COMPLETE THE CAUSE OF DEATH?

Yes No

35. DID TOBACCO USE CONTRIBUTE

TO DEATH?

Yes Probably

No Unknown

36. IF FEMALE:

Not pregnant within past year

Pregnant at time of death

Not pregnant, but pregnant within 42 days of death

Not pregnant, but pregnant 43 days to 1 year before death

Unknown if pregnant within the past year

37. MANNER OF DEATH

Natural Homicide

Accident Pending Investigation

Suicide Could not be determined

Acute respiratory illness 1 day

5 days

Probable COVID-19

Ischemic stroke

Scenario III

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Scenario IV: A 48-year-old male with post-acute

sequelae of COVID-19

A healthy 48-year-old male had severe respiratory symptoms,

severe fatigue, and brain fog in the course of an acute SARS-

CoV-2 infection. He did not require hospitalization and gradually

improved over several weeks. Fatigue and exercise intolerance

persisted. Clinical examination and imaging revealed severe

cardiac dilatation with ongoing myocardial injury; heart biopsies

indicated lymphocytic myocarditis. The patient was stable for

several months but gradually developed severe congestive heart

CAUSE OF DEATH (See instructions and examples)

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac

arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional

lines if necessary.

IMMEDIATE CAUSE (Final

disease or condition ---------> a._____________________________________________________________________________________________________________

resulting in death) Due to (or as a consequence of):

Sequentially list conditions, b._____________________________________________________________________________________________________________

if any, leading to the cause Due to (or as a consequence of):

listed on line a. Enter the

UNDERLYING CAUSE c._____________________________________________________________________________________________________________

(disease or injury that Due to (or as a consequence of):

initiated the events resulting

in death) LAST d._____________________________________________________________________________________________________________

Approximate

interval:

Onset to death

_____________

33. WAS AN AUTOPSY PERFORMED?

Yes No

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

34. WERE AUTOPSY FINDINGS AVAILABLE TO

COMPLETE THE CAUSE OF DEATH?

Yes No

35. DID TOBACCO USE CONTRIBUTE

TO DEATH?

Yes Probably

No Unknown

36. IF FEMALE:

Not pregnant within past year

Pregnant at time of death

Not pregnant, but pregnant within 42 days of death

Not pregnant, but pregnant 43 days to 1 year before death

Unknown if pregnant within the past year

37. MANNER OF DEATH

Natural Homicide

Accident Pending Investigation

Suicide Could not be determined

Congestive heart failure

weeks

months

Dilated cardiomyopathy

Lymphocytic myocarditis

Post-acute sequelae of COVID-19

Scenario IV

failure. He died in hospital. Autopsy revealed marked four-

chamber dilatation of the heart with diffuse myocardial fibrosis

of the ventricles.

Comment: In this instance, the immediate cause of death was

congestive heart failure, so it was reported on line a., which was

due to the dilated cardiomyopathy reported on line b., which was

a consequence of the lymphocytic myocarditis reported on line

c. The UCOD was post-acute sequelae of COVID-19, so it was

reported on line d., the lowest line used in Part I.

U.S. Department of Health and Human Services • Centers for Disease Control and Prevention • National Center for Health Statistics • National Vital Statistics System

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Centers for Disease Control and Prevention

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Vital Statistics Reporting Guidance

Contents

Introduction ....................................................1

Cause-of-Death Reporting ........................................1

Part I ......................................................1

Approximate interval: Onset to death .............................1

Part II .....................................................2

Certifying deaths due to COVID-19 ..............................2

Common problems ...........................................2

Certifying deaths due to post-acute sequelae of COVID-19 ...........2

Manner of death .............................................3

When to Refer to a Medical Examiner or Coroner ......................3

Conclusion ....................................................3

References .....................................................3

Appendix. Scenarios and Example Certifications for

Deaths Due to COVID-19 ........................................5

Acknowledgments

NCHS would like to acknowledge Marcus Nashelsky, M.D., for his

contributions to the guidance and example certifications.

Suggested citation

National Center for Health Statistics. Guidance for certifying deaths due to

coronavirus disease 2019 (COVID-19). Expanded in February 2023 to include

guidance for certifying deaths due to post-acute sequelae of COVID-19.

Hyattsville, MD. 2023. DOI: https://dx.doi.org/10.15620/cdc:124588.

All material appearing in this report is in the public domain and may be

reproduced or copied without permission; citation as to source, however, is

appreciated.

National Center for Health Statistics

Brian C. Moyer, Ph.D., Director

Amy M. Branum, Ph.D., Associate Director for Sciencee

Division of Vital Statistics

Steven Schwartz, Ph.D., Director

Andrés A. Berruti, Ph.D., M.A., Associate Director for Science

For e-mail updates on NCHS publication releases, subscribe online at:

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DHHS Publication No. 2023–1126 • CS337688