TEXT: This HPLHS Prop Document is for entertainment purposes only. It is intended for personal use in role-playing games, and 
  you are free to customize and print copies for such purposes. Any commercial or illegal use of this digital file or the prop you can 
  make from it is entirely prohibited. Designed and implemented by Andrew Leman. ©2008 by HPLHS Inc. This work is licensed 
  under the Creative Commons Attribution-Noncommercial-Share Alike 3.0 United States License. To view a copy of this license, 
  visit http://creativecommons.org/licenses/by-nc-sa/3.0/us/ or send a letter to Creative Commons, 171 Second Street, Suite 300, 
  San Francisco, California, 94105, USA.  Questions? Ask them! leman@cthulhulives.org
  www.cthulhulives.org
  DEATH CERTIFICATE
  This prop is a replica of a genuine vintage death certificate. This is a certified copy of the original docu-
  ment, such as might be requested by an investigator after the fact.
  Enter information on form using built-in Acrobat form fields (or delete default entries and print prop 
  “blank”, and enter info using a real typewriter or by hand).
  Print on any kind of paper you want. The certificate on page 2 is meant to be printed on plain white or solid 
  colored paper. The certificate on page 3 is intended for printing on paper with a pre-printed certificate bor-
  der, such as can be found at various office supply stores.
  Add handwritten remarks, rubber stamped dates, and other details for added authenticity. Ideally, an em-
  bossed state seal would appear in the lower left corner.
  GENERAL INSTRUCTIONS FOR FILLING OUT DEATH CERTIFICATES
  The death certificate is designed to identify causes of death and how these conditions related to each other and to the death. The death certificate should 
  not be used to document the deceased’s entire medical history for posterity. Do not report diseases, injuries, other conditions or circumstances that did 
  not cause or contribute to death. 
  DEFINITIONS
  Cause(s) of Death. “Cause of death” is a morbid condition or disease process, abnormality, injury or poisoning leading directly or indirectly to death. 
  Immediate Cause of Death. This is the final disease or condition that resulted directly in death. Chronologically, it is the last medical condition to occur.
  Intermediate Cause(s) of Death. These are conditions that link the immediate cause of death to the underlying cause.
  Underlying Cause of Death. This is the disease or injury which “initiated the train of morbid events leading directly to death or the circumstances of the 
  accident or violence which produced the fatal injury.”
  Contributing Cause(s) of Death. “Contributing causes” are diseases, injuries, or other conditions that contributed to the fatal outcome, but did not cause 
  the condition identified as the underlying cause of death.
  Injury. If you report an injury on a death certificate, you are saying it was a cause of death. For purposes of coroner notification, “injury” includes the fol-
  lowing:
  LIST OF TERMS THAT DO NOT ADEQUATELY IDENTIFY UNDERLYING CAUSE OF DEATH
  Certain terms should not be reported as the only cause(s) of death because they do not identify the underlying cause of death. These terms describe 
  only symptoms, signs of illness, ill-defined terms, plus secondary conditions. This is not an all-inclusive list.
  UNKNOWN  AND  UNCERTAIN  CAUSE  OF  DEATH
  Cause of death is an opinion based upon best available knowledge, but the person who completes the cause of death section and signs the death certifi-
  cate should be someone who knows the causes of death, including the underlying cause of death. If you know only the probable causes of death, you may 
  report those. If “unknown” is all you can report, include a statement on the death certificate that explains why the cause of death was unknown. 
  age, (old) (any)
  altered mental status
  anorexia
  anoxia
  anuria
  arrest, cardiac
  arrest, cardiopulmonary
  arrest, cardiorespiratory
  arrest, respiratory
  arrhythmia
  ascites
  aspiration
  asystole
  bacteremia
  bedridden
  bradycardia
  cachexia
  coagulopathy
  coma
  convulsions
  death, cardiac
  death, neonatal
  debility, senile
  debility, unspec.
  decubiti
  dehydration
  depletion, volume
  diarrhea
  difficulty feeding
  dissociation, electromechanical
  distress, adult respiratory
  dysphagia
  dysrhythmia
  dysrhythmia, cardiac
  edema
  edema, cerebral
  edema, pulmonary
  effusion, pleural
  exhaustion
  exsanguination
  failure to thrive
  failure, any organ
  failure, central nervous system
  failure, heart
  failure, heart, congestive
  failure, hepatic
  failure, liver
  failure, multi organ
  failure, multi system
  failure, respiratory
  fever
  fibrillation, atrial
  fibrillation, ventricular
  gangrene (incl. of site)
  hemothorax
  homeostenosis
  hyperglycemia
  hyperkalemia
  hyponatremia
  hypotension
  hypothermia, unspec.
  hypoxia
  immaturity
  immunosuppression
  increased intracranial pressure
  insufficiency, pulmonary
  jaundice
  loss, weight
  natural causes (unk.)(unspec.)
  nonviable
  paraplegia
  prematurity
  quadriplegia
  rapid heart beat
  seizures
  senescence
  senile debility exhaustion
  senility
  shock
  shock, cardiogenic
  shock, hypovolemic
  shock, septic
  shock, unspec.
  shutdown of specified organ(s)
  slow heart beat
  state, chronic bedridden
  syncope
  tachycardia
  vomiting
  weak heart
  • trauma from external forces
  • other adverse physical effects of externally-caused events
  • poisoning, toxicity or overdose of any substance, including 
  medication
  • exposure to natural and environmental forces such as weather
  • aspiration, suffocation, strangulation, mechanical obstruction 
  of breathing including from food, vomitus, secretions (unless 
  reported due to disease)
  • anaphylactic shock and other allergic reactions
  • fractures and hematomas from falls or other external forces
  • errors and accidents during surgery or other medical care
  • starvation, neglect, privation
  • overexertion
  • contact with venomous or nonvenomous animals, insects, plants, 
  gigantic monstrous multi-eyed tentacular horrors
  
  ********************
  ********************
  ********************
  ********************
  ********************
  ******************** 
  ********************
  ********************
  ******************** 
  ********************
  ********************
  ******************** 
  ********************
  ********************
  ******************** 
  ********************
  ********************
  ******************** 
  ********************
  ********************
  ******************** 
  ********************
  ********************
  ******************** 
  ********************
  ********************
  ********************
  STATE  BOARD  OF  HEALTH
  Bureau of Vital Statistics
                
   
   
   
   
   
  No.
       I,   
   
   
   
   yfitrec y
  bereh o
  d ,scitsitatS
   lati
  V
   fo rartsige
  R
   etatS
    ,                  
  the following to be a true and correct copy of the CERTIFICATE OF DEATH of
  on file in THE BUREAU OF VITAL STATISTICS.
  Registration  District  No. 
   
   
                     File    No.
  Primary  Registration  District  No. 
            
                 Registered  No.
  (No. 
    
   
   
   
               St.                            Ward)
         FULL  NAME
  (If death occurred in 
  a Hospital or Institution, 
  give its NAME instead of 
  street and number.)
  (If  death  occurs  away  from 
  USUAL  RESIDENCE 
  give  facts  called  for  under
  “Spcial  Information.”)
                          PLACE   OF   DEATH
  County  of
  Voting  Precinct  No.
  Incorporated  Town
  City
  IN TESTIMONY WHEREOF, I have hereunto subscribed my name and 
  caused the official seal to be affixed at
  this 
   
   
     day of
  in the year of our Lord one thousand nine hundred and
   
   
   
   
   
   
   
      State  Registrar.
  IF  LESS  than
  1  day      hrs.
  or 
   
  min?
  PERSONAL  AND  STATISTICAL  PARTICULARS
  MEDICAL  CERTIFICATE  OF  DEATH
  PARENTS
  3.  SEX
  4.  COLOR  OR  RACE
  6. DATE  OF  BIRTH
   
   
   
   
   
   
      1
   
   
            (Month)                 (Day)                    (Year)
  16. DATE  OF  DEATH
   
   
   
   
   
   
          19
   
   
            (Month)                 (Day)                    (Year)
  17.  
   
              I  HEREBY  CERTIFY    That I attended deceased
  from 
   
               ,  19              to 
   
   
         ,   19
  that  I  last  saw  h              alive on                                              ,  19
  and  that  death  occurred  on  the  date  stated  above  at
  m. THE CAUSE OF DEATH was as follows:
   
   
   
  (Duration) 
   
  yrs. 
   
  mos. 
   
  ds.
  Contributory
           (Secondary)
   
   
   
  (Duration) 
   
  yrs. 
   
  mos. 
   
  ds.
  (Signed)                                                                                      ,  M.  D.
                                                   ,  19                (Address)
  7. AGE
                                    yrs.                     mos.                          ds.
  8. OCCUPATION
  (a)  Trade, profession or
  particular kind of work
  (b)  General nature of industry,
  business or establishment in which 
  employed (or employer)
  9. BIRTHPLACE
  (State or country)
  14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
      (Informant)
                                          (Address)
  10. NAME OF
   
  FATHER
  Filed 
   
    19
  Registrar.
  11. BIRTHPLACE
   
  OF FATHER
   
  (State or country)
  12. MAIDEN NAME
   
  OF MOTHER
  13. BIRTHPLACE
   
  OF MOTHER
   
  (State or country)
  5.  Single
      Married
      Widowed
      or  Divorced
   ses
  u
  a
  C
    t
  n
  eloi
  V
    
  m
  o
  rf  s
  h
  ta
  e
  d  
  n
  i  ,r
  o  ,h
  ta
  e
  D
    
  g
  n
  is
  u
  a
  C
    es
  a
  esi
  D
    e
  h
  t  etat
  S
  *   
   r
  o
    la
  diciu
  S
    ,lat
  n
  e
  dicc
  A
    re
  h
  te
  h
  w
    )2(   
  d
  n
  a
    ;y
  r
  uj
  n
  I
    f
  o
    s
  n
  a
  e
  M
    )1(  etats
  Homicidal.
   r
  o
    st
  n
  eis
  n
  a
  r
  T
    ,s
  n
  oitutits
  n
  I  ,slatip
  so
  H
    r
  o
  F
  (  
  E
  C
  N
  E
  D
  I
  S
  E
  R
    
  F
  O
    
  H
  T
  G
  N
  E
  L
   .8
  1
  Recent  Residents)
  At place 
   
   
   
           In the
  of death                  yrs.                 mos.                 ds.         State        yrs.         mos.       ds.
  Where  was  disease  contracted
  If  not  at  place  of  death?
  Former  or
  usual  residence
  19. PLACE  OF  BURIAL  OR  REMOVAL          DATE  OF  BURIAL
  20. UNDERTAKER                                      ADDRESS
  HPLHS printing co.
  COMMONWEALTH   OF   MASSACHUSETTS
  BOSTON,  MASSACHUSETTS
  81772
  Edgar Firth
  Allan Halsey
  Essex
  12
  Arkham
  34
  2876877-B
  1266
  81772
  St. Mary's Hospital
  Allan Graham Halsey
  Male
  White
  Married
    August    14
  05
       July      12
  837
  68
  1
  2
    Physician
  Medicine
  Pennsylvania
  George Everett Halsey
     Penna.
  Edith Graham
     Missouri
  08/12
  25
  08/14
  05
  im
  August 14
  05
    2:43 p
  Enteric Fever
    with pulmonary complications
    due to Typhus infection
   3
  Exhaustion
   advanced age
  14
  Edward Moore
    August 14
  05
  Arkham, Mass.
  Arkham, Mass.
  Christchurch Cemetery
   Aug 17
  Gunnar Bachlund
  Arkham
  Herbert West
  Arkham
  8/20
  05
  Perkins
  Boston
     26th
    September
  twenty-seven.
  
  STATE  BOARD  OF  HEALTH
  Bureau of Vital Statistics
                
   
   
   
   
   
  No.
       I,   
   
   
   
   yfitrec y
  bereh o
  d ,scitsitatS
   lati
  V
   fo rartsige
  R
   etatS
    ,                  
  the following to be a true and correct copy of the CERTIFICATE OF DEATH of
  on file in THE BUREAU OF VITAL STATISTICS.
  Registration  District  No. 
   
   
                     File    No.
  Primary  Registration  District  No. 
            
                 Registered  No.
  (No. 
    
   
   
   
               St.                            Ward)
         FULL  NAME
  (If death occurred in 
  a Hospital or Institution, 
  give its NAME instead of 
  street and number.)
  (If  death  occurs  away  from 
  USUAL  RESIDENCE 
  give  facts  called  for  under
  “Spcial  Information.”)
                          PLACE   OF   DEATH
  County  of
  Voting  Precinct  No.
  Incorporated  Town
  City
  IN TESTIMONY WHEREOF, I have hereunto subscribed my name and 
  caused the official seal to be affixed at
  this 
   
   
     day of
  in the year of our Lord one thousand nine hundred and
   
   
   
   
   
   
   
      State  Registrar.
  IF  LESS  than
  1  day      hrs.
  or 
   
  min?
  PERSONAL  AND  STATISTICAL  PARTICULARS
  MEDICAL  CERTIFICATE  OF  DEATH
  PARENTS
  3.  SEX
  4.  COLOR  OR  RACE
  6. DATE  OF  BIRTH
   
   
   
   
   
   
      1
   
   
            (Month)                 (Day)                    (Year)
  16. DATE  OF  DEATH
   
   
   
   
   
   
          19
   
   
            (Month)                 (Day)                    (Year)
  17.  
   
              I  HEREBY  CERTIFY    That I attended deceased
  from 
   
               ,  19              to 
   
   
         ,   19
  that  I  last  saw  h              alive on                                              ,  19
  and  that  death  occurred  on  the  date  stated  above  at
  m. THE CAUSE OF DEATH was as follows:
   
   
   
  (Duration) 
   
  yrs. 
   
  mos. 
   
  ds.
  Contributory
           (Secondary)
   
   
   
  (Duration) 
   
  yrs. 
   
  mos. 
   
  ds.
  (Signed)                                                                                      ,  M.  D.
                                                   ,  19                (Address)
  7. AGE
                                    yrs.                     mos.                          ds.
  8. OCCUPATION
  (a)  Trade, profession or
  particular kind of work
  (b)  General nature of industry,
  business or establishment in which 
  employed (or employer)
  9. BIRTHPLACE
  (State or country)
  14. THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
      (Informant)
                                          (Address)
  10. NAME OF
   
  FATHER
  Filed 
   
    19
  Registrar.
  11. BIRTHPLACE
   
  OF FATHER
   
  (State or country)
  12. MAIDEN NAME
   
  OF MOTHER
  13. BIRTHPLACE
   
  OF MOTHER
   
  (State or country)
  5.  Single
      Married
      Widowed
      or  Divorced
   ses
  u
  a
  C
    t
  n
  eloi
  V
    
  m
  o
  rf  s
  h
  ta
  e
  d  
  n
  i  ,r
  o  ,h
  ta
  e
  D
    
  g
  n
  is
  u
  a
  C
    es
  a
  esi
  D
    e
  h
  t  etat
  S
  *   
   r
  o
    la
  diciu
  S
    ,lat
  n
  e
  dicc
  A
    re
  h
  te
  h
  w
    )2(   
  d
  n
  a
    ;y
  r
  uj
  n
  I
    f
  o
    s
  n
  a
  e
  M
    )1(  etats
  Homicidal.
   r
  o
    st
  n
  eis
  n
  a
  r
  T
    ,s
  n
  oitutits
  n
  I  ,slatip
  so
  H
    r
  o
  F
  (  
  E
  C
  N
  E
  D
  I
  S
  E
  R
    
  F
  O
    
  H
  T
  G
  N
  E
  L
   .8
  1
  Recent  Residents)
  At place 
   
   
   
           In the
  of death                  yrs.                 mos.                 ds.         State        yrs.         mos.       ds.
  Where  was  disease  contracted
  If  not  at  place  of  death?
  Former  or
  usual  residence
  19. PLACE  OF  BURIAL  OR  REMOVAL          DATE  OF  BURIAL
  20. UNDERTAKER                                      ADDRESS
  COMMONWEALTH   OF   MASSACHUSETTS
  BOSTON,  MASSACHUSETTS
  81772
  Edgar Firth
  Allan Halsey
  Essex
  12
  Arkham
  34
  2876877-B
  1266
  81772
  St. Mary's Hospital
  Allan Graham Halsey
  Male
  White
  Married
    August    14
  05
       July      12
  837
  68
  1
  2
    Physician
  Medicine
  Pennsylvania
  George Everett Halsey
     Penna.
  Edith Graham
     Missouri
  08/12
  25
  08/14
  05
  im
  August 14
  05
    2:43 p
  Enteric Fever
    with pulmonary complications
    due to Typhus infection
   3
  Exhaustion
   advanced age
  14
  Edward Moore
    August 14
  05
  Arkham, Mass.
  Arkham, Mass.
  Christchurch Cemetery
   Aug 17
  Gunnar Bachlund
  Arkham
  Herbert West
  Arkham
  8/20
  05
  Perkins
  Boston
     26th
    September
  twenty-seven.
  
SOURCE: textdata/thevault/Call of Cthulhu (CoC) (BRP) [multi]/EXTRA/Resources/Props/CoC - Prop - Death Certificate.pdf