REGISTRATION

Registracija STATE OF ILLINOIS

Okružni
DISTRICTbroj.
NO.
CERTIFICATE OF DEATH
LOKALNI FAJL
LOCAL FILE
Broj STATE FILE NUMBER
NUMBER
1.1.DECEDENTOV PRAVNI
DECEDENT'S LEGAL NAZIV
NAME (Uključi
(Include AKAs if AKA-e ako
any) (First, ih ima)
Middle, Last) (Prvo, Srednje, Posljednje) 2.SEX
2. SEX DATUM
3. DATE SMRTI (mjesec
OF DEATH / dan / godina)
(Month/Day/Year) (mjesec uroka)
(Spell Month)

Zemlja smrti
4. COUNTY OF DEATH 5a. DOBA U POSLJEDNJI
AGE AT ROĐENDAN
LAST BIRTHDAY (Godine) 5b.
(Years) 5b.. UNDER
ISPOD 1 GODINE
1 YEAR ISPOD 1 1
5c. UNDER DANA
DAY 6.
6. DATUM
DATE OFROĐENJA (mjesec / dan / godina)
BIRTH (Month/Day/Year)
Months Days Hours Minutes

7a. GRADOR
7a. CITY ILI TOWN
SELO 7b. NAZIV BOLNICE
HOSPITAL ILI OSTALE
OR OTHER USTANOVE
INSTITUTION (Ako(Ifnijedna
NAME nije navedena,
not in either, navedite
give street and number)ulicu i broj)
(Based on the 2003 U.S. Standard Certificate)

PLACE
7c. PLACE
MJESTOOF
OF DEATH
DEATH
SMRTI (Check
(Check
(Označite only
only
samo one;
one; see see
jedno; instructions)
instructions)
pogledajte upute)
IF DEATH
IFAKO OCCURRED
SE OCCURRED
DEATH SMRT ININ
dogodi A HOSPITAL
uA bolnici
HOSPITAL AKO SE SMRT
IF DEATH NAGODILA
OCCURRED NEGDJE
SOMEWHERE OSIM
OTHER THANBOLNICE
HOSPITAL

Stacionarni
Inpatient Hitna pomoć
Emergency / ambulantno
Room/Outpatient Mrtvionna
Dead dolasku
Arrival Staracki Dom
Hospice Facility / Ustanova
Nursing za dugotrajnu
Home/Long-Term njegu
care facility Pokojnikov
Decedent's dom
Home Ostalo / Navedite
Other (Specify):

8. ROĐENJE
BIRTHPLACE 9. BROJ SOCIJALNOG
SECURITY OSIGURANJA BRAČNI STATUS
STATUSU AT
VRIJEME SMRTI PREŽIVJENO IME BRAČNIKA
SOCIAL NUMBER 10. MARITAL TIME OF DEATH 11. SURVIVING SPOUSES NAME EVER IN
12. EVER IN THE
THE US
US
(Grad
(City and iState
država ili strana
or Foreign država)
Country) (If wife, give full name prior to first marriage) ARMED FORCES?
ARMED FORCES?
Married Married but separated Widowed

Divorced Never Married Unknown YES NO

13a. Država gdje (Street

RESIDENCE živi and Number) 13b.BROJ STAN.
APT. NO. GRAD
13c. CITY ORILI SELO
TOWN 13d. UNUTAR OGRANIČENJA
INSIDE CITY LIMITS? GRADA?

- Yes No

13e. Drzava
COUNTY 13f.STATE
STATE 13g.POŠTANSKI
ZIP CODEBROJ 14. OČEVO IME (Prvo,
FATHER'S NAMESrednje, Posljednje)
(First, Middle, Last) 15. IME MAJKE PRIJE
MOTHER'S NAME PRVOG BRAKA
PRIOR TO (Prvi,
FIRST Srednji, Posljednji)(First, Middle, Last)
MARRIAGE

IME INFORMATORA
16a. INFORMANT'S NAME ODNOS
16b. RELATIONSHIP ADRESAADDRESS
16c. MAILING ZA POŠTU (ulica
(Street i br.,City
and No., Grad ili mjesto,
or Town, State, ZIPdržava,
Code) poštanski broj)

17. METHOD OF DISPOSITION: Burial MJESTO

18. PLACE OFODLAGANJA (nazivofgroblja,
DISPOSITION (Name cemetery, krematorija,
crematory, other)ostalo) 19. .LOCATION
LOKACIJA- CITY,
- GRAD, GRAD
TOWN ANDISTATE
DRŽAVA 20. DATUM ODLAGANJA
DATE OF (mjesec(Month/Day/Year)
DISPOSITION / dan / godina
Cremation Donation Entombment

Other (Specify):
POGREBNAHOME
21a. FUNERAL KUĆA IME
NAME STREET NUMBER ULICA
CITY ORBROJ
TOWN GRAD ILI DRŽAVA DRŽAVA
STATE ZIP POŠTANSKI BROJ
Illinois Department of Public Health - Division of Vital Records

21b.POTPIS POGREBNOG
FUNERAL DIREKTORA
DIRECTOR'S SIGNATURE 21c. .FUNERAL
POGREBNI DIREKTORI ILLINOIS
DIRECTOR'S ILLINOIS LICENSE
BROJ LICENCE
NUMBER

DATUM PRIJAVLJEN LOKALNIM REGISTAROM (mjesec / dan / godina)

POTPIS
22. LOCAL LOKALNOGSIGNATURE
REGISTRAR'S REGISTRA 23. DATE FILED WITH LOCAL REGISTRAR (Month/Day/Year)

CAUSE OF DEATH (See instructions and examples) PRIBLIŽNI INTERVAL

APPROXMATE INTERVAL
. . DIOI. I. Enter
Uđite the
u lanac IZMEĐU UGROŽENE I SMRTI
24. PART chaindogađaja
of events- -bolesti,
diseases, ozljeda ili komplikacija
injuries - koji- that
or complications izravno uzrokuju
directly causesmrt. NE unosite
the death. DO NOTterminalne događaje
enter terminal poput
events suchsrčanog zastoja,
as cardiac arrest, BETWEEN ONSET AND DEATH
zastoj disanja
respiratory ili ventrikularna
arrest fibrilacija bez
or ventricular fibrillation pokazivanja
without etiologije.
showing etiology. Akodecedent
If the je ostavitelj
hadimao bolest povezanu
a dementia s demencijom,
related disease, Parkinsonovom
Parkinson's bolešću ili Parkinsonom
Disease, or Parkinson
Kompleks demencije, naznačiti u I. ili II. Dijelu. NE SKRAĆATI. Na liniji unesite samo jedan uzrok. Po potrebi
Dementia Complex, indicate in Part I or Part II. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. dodajte dodatne retke.

NEPOSREDNI UZROK
IMMEDIATE
(Gljivična bolest CAUSE (Final
ili stanje koje disease
rezultira smrću)
or condition resulting in death) a.
Zbog
Due to (or(ili
askao posljedica):
a consequence of):
Redoslijed
Sequentially popisa uvjeta, ako postoje,
list conditions, if any,
što dovodi
leading todo
theuzroka
causenavedenog na lina
listed on lina a. a. b.
Unesite donji razlog Due toZbog (ili kao
(or as posljedica):
a consequence of):
Enter the UNDERLYING
(bolest ili ozljeda pokrenula
CAUSE
(diseasekoji
događaji or injury initiated
rezultiraju the
smrću) POSLJEDNJI
events resulting in death) LAST c.
Due toZbog
(or (ili
askaoa consequence
posljedica): of):

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I. JE LI AN
25. WAS IZVRŠENA AUTOPSIJA?
AUTOPSY PERFORMED? Yes No

26. WERE AUTOPSY FINDINGS USED TO

COMPLETE CAUSE OF DEATH? Yes No

Dali TOBACCO
27. DID je duhan bioUSE
razlog smrti 28. IF FEMALE: 29. NAČIN
MANNERSMRTI
OF DEATH
CONTRIBUTE TO DEATH? Not pregnant within the past 12 months Pregnant at time of death Prirodno Nije moguće utvrditi
Natural Samoubojstvo
Suicide Could not be determined
Da
Yes Mozda
Probably Not pregnant within 42 days of death Pregnant within one year of death but time unknown
Nesreća
Accident Umorstvo
Homicide Na čekanju
Pending istraga
Investigation
Ne Ne zna Not pregnant, but pregnant 43 days to 1 year before death. Unknown if pregnant within the past 12 months
No Unknown
VR200 (Rev. 1/08)

30. DATUM OZLJEDE

DATE OF INJURY(mjesec / dan / godina)
(Month/Day/Year) 31.VRIJEME
TIME OFOZLJEDE
INJURY 32. MJESTO POVREDE
PLACE OF (npr. Decedent's
INJURY (e.g. Dom naslednika;
home;gradilište, restoran,
construction site, šumovito područje)
restaurant, wooded area) 33. POVREDA
INJURY ATNA RADU?
WORK?

A.M. P.M. Yes No

GRAD ILI SELO

StateSTATE POŠTANSKI BROJ
LOKACIJA POVREDE Ulica i broj BROJ STAN
34. LOCATION OF INJURY Street and Number Apartment Number City or Town ZIP Code

35. DESCRIBE HOW INJURY OCCURRED: 36.AKO

36. IF TRANSPORTATION INJURY,
OZLJEDA PRIJEVOZA, SPECIFY:
NAVEDITE:
Driver/Operator
36. AKO OZLJEDA PRIJEVOZA, NAVEDITE: Pedestrian
Pješak

Passenger
Putnik Other (Specify):
Drugo

37. IJESAM
(DID) (NISAM) (NISAM)
(DID NOT) PRISUSTVOVAO
ATTEND Smanjenom (mjesec
THE DECEASED / dan / godina)
(Month/Day/Year) DA LI JE
38. WAS BIO KONTAKT
MEDICAL MEDICINSKOGOR
EXAMINER PREGLEDNIKA ILI KUTKA? 39. .DATE
IZNOSENI DATUM (mjesec(Month/Day/Year)
PRONOUNCED / dan / godina) VRIJEME SMRTI
40. TIME OF DEATH
I POSLJEDNJI GA / NJEGA ŽIVO
AND LAST SAW HIM/HER ALIVE CORONER CONTACTED?
Yes No
A.M. P.M.
CERTIFIKATOR (Označite samo jedan):
41. CERTIFIER (Check only one):
Liječnik zadužen za njegu pacijenta - Prema mojim saznanjima, smrt se dogodila zbog navedenih uzroka i načina.
Physician in charge of patient's care - To the best of my knowledge, death occurred due to the cause(s) and manner stated.
Liječnik kojiinjeattendance
Physician prisutan samo u vrijeme
at time smrti
of death - Prema
only mojim
- To the bestsaznanjima, smrt sedeath
of my knowledge, dogodila u vrijeme,
occurred datum
at the time,i mjesto, i toplace,
date, and zbog uzroka
and duei načina navedenog.
to the cause(s) and manner stated.
Medical Examiner/Coroner
Medicinski - On-the
ispitivač / mrtvozornik Na basis
osnovuof pregleda
examination
i / ili and/or
istrage,investigation, in my smrt
po mom mišljenju, opinion, death occurred
se dogodila at datum
u vrijeme, the time, date and
i mjesto, place,
te zbog and dueuzroka
navedenih to the cause(s)
i načina. and manner stated.
IME, ADRESA
42. NAME, I POSTANSKI
ADDRESS, BROJ OF
AND ZIP CODE OSOBE KOJACOMPLETING
PERSON ZAVRŠUJE UZROK
CAUSESMRTI (točka (Item
OF DEATH 24) 24) 43.. PHYSICIAN'S
BROJ LICENCE LIJEČNIKA
LICENSE NUMBER

NASLOV
44. TITLE POTVRDE
OF CERTIFIER 45. DATUM Ovjeren (mjesec
DATE CERTIFIED / dan / godina)
(Month/Day/Year) . POTPIS POTVRDE
46. SIGNATURE OF CERTIFIER

47.OBRAZOVANJE
47. DECEDENT'S DECEDENTA
EDUCATION -- CheckProverite
the 48. DECEDENT OF HISPANIC ORIGIN? - Check the box that best DECEDENTOVA
49. DECEDENT'S RASA
RACE - Označite
- Check one jednu ili više
or more rasa
races to kako bistewhat
indicate naznačili što je preminuo
the decedent
kutija kojabest
box that najbolje opisujethe
describes najviši stepen
highest odn or
degree describes whether the decedent is Spanish/Hispanic/Latino. sebe smatrao.
considered himself or herself to be.
nivo škole završen u vreme smrti.
level of school completed at the time of death. Check the "No" box if decedent is not Spanish/Hispanic/Latino.
Bijela
Whiterasa Black or African American
8.8th
razred ili manje
grade or less No, Not Spanish/Hispanic/Latino
9. - 12. razred; bez diplome American Indian or Alaskan Native
9th - 12th grade; no diploma Yes, Mexican American, Chicano
Maturant ili GED završen
(Name of the enrolled or principle tribe)
High school graduate or GED completed
Neki kredit na fakultetu, ali bez diplome Yes, Puerto Rican
Some college credit, but no degree Korean
Izvanredni stupanj (npr. AA, AS) Asian Indian Chinese Filipino Japanese
Yes, Cuban
Asssociate degree (e.g. AA, AS)
Prvostupnik (npr. BA, AB, AS)
Bachelor's degree (e.g. BA, AB, AS)
Yes, other Spanish/Hispanic/Latino Vietnamese Other Asian (Specify)
Magisterij (npr. MA, MS, MEng,
MED, MSW, MBA)
Master's degree (e.g. MA, MS, MEng, Specify: Native Hawaiin Guamanian or Chamorro Samoan
Doktorat
MEd, MSW,(npr. MBA)
Doktorat, edd) ili

Stručna diploma
Doctorate (e.g.(npr.
PhD,MD, DDS,
EdD) or Other Pacific Islander (Specify)
DVM, LLB, JD) degree (e.g. MD, DDS,
Professional
DVM, LLB, JD)
Other (Specify)
Nepoznato
Unknown

50. .DECEDENT'S
DECEDENT'SUSUAL
USUAL OCCUPATION
OCCUPATION (Indicate type
(Indicate type of work
of work donedone during
during most
most of of working
working life. DO
life. DO NOT NOT
USE USE RETIRED).
RETIRED). BUISNESS/INDUSTRY(Enter
51. BUISNESS/INDUSTRY (Enter type
type of buisness
of buisness or industry,
or industry, NOT COMPANY
NOT COMPANY NAME)NAME)

Printed by the Authority of the State of Illinois

P.O. #148109 150M 7/07