U.S. Vital Statistics SystemOrganization of the Vital Statistics System" to 1950 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center

CENTERS FOR DISEASE CONTROL

AND PREVENTION

U.S. VitalStatistics SystemU.S. VitalStatistics SystemMajor Activities and Developments, 1950-95

From the CENTERS FOR DISEASE CONTROL AND PREVENTION/National Center for Health Statistics

Includes reprint of "History and

Organization of the Vital Statistics

System" to 1950

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

National Center for Health StatisticsEdward J. Sondik, Ph.D.,Director

Jack R. Anderson,Deputy Director

Jack R. Anderson,Acting Associate Director forInternational Statistics

Lester R. Curtin, Ph.D.,Acting Associate Director forResearch and Methodology

Jacob J. Feldman, Ph.D.,Associate Director for Analysis,Epidemiology, and Health Promotion

Gail F. Fisher, Ph.D.,Associate Director for Data Standards,Program Development, and Extramural Programs

Edward L. Hunter,Associate Director for Planning, Budget,and Legislation

Jennifer H. Madans, Ph.D.,Acting Associate Director forVital and Health Statistics Systems

Stephen E. Nieberding,Associate Director forManagement

Charles J. Rothwell,Associate Director for DataProcessing and Services

Division of Vital Statistics

Mary Anne Freedman,Director

James A. Weed, Ph.D.,Deputy Director

George A. Gay,Special Assistant for Registration Methods

Harry M. Rosenberg, Ph.D.,Chief, Mortality StatisticsBranch

Vacant,Chief, Reproductive Statistics Branch

Nicholas F. Pace,Acting Chief, Systems, Programming, andStatistical Resources Branch

Ronald F. Chamblee,Chief, Data Acquisition and EvaluationBranch

Acknowledgments

This report was prepared by Alice M. Hetzel under contract with the National Association for PublicHealth Statistics and Information Systems (NAPHSIS), formerly the Association for Vital Records and HealthStatistics (AVRHS).

The author is grateful to NAPHSIS for sponsoring this update of the history of the vital statistics systemin the United States. Special recognition is owed to Mary Anne Freedman and Frederick L. King, who, duringtheir tenure as officers and executive committee members of AVRHS, actively supported initiation of theproject. The association sought the cooperation of the National Center for Health Statistics (NCHS) andgained the support of Manning Feinleib, M.D., Dr. P.H., former Director of NCHS, and John E. Patterson,former Director of the Division of Vital Statistics. Coordination between NAPHSIS and NCHS was expertlyprovided under the leadership of George A. Gay, Chief, Registration Methods Branch, Division of VitalStatistics.

Many persons within NAPHSIS and NCHS contributed to the production of this history with suggestionsfor subjects to be included and help in locating pertinent reports and memoranda and in processing the finalmanuscript for publication. The author is especially indebted to Judy M. Barnes of the Registration MethodsBranch for her technical assistance with the content of the report and with the activities associated with itspublication. Specific acknowledgment is made to the following reviewers, whose comments helped shape thereport: Robert Bilgrad, Linda Bordonaro, John Brockert, Joe Carney, Ronald Chamblee, Marshall Evans,Joseph Farrell, Mary Anne Freedman, Donna Glenn, Robert D. Grove, Ph.D., Nancy Hamilton, Susan Hawk,Robert Heuser, Frederick L. King, A. Joan Klebba, Michael Kogan, Ph.D., Julia Kowaleski, William Mosher,Stephanie Mounts, Sherry Murphy, William Pratt, Mabel Smith, James Spitler, George Van Amburg, andJames A. Weed, Ph.D.

Manuscript preparation was ably and patiently prepared by Gayle Shannon. This report was edited byDemarius V. Miller and typeset by Zung T.N. Le, Division of Data Services, Publications Branch.

iii

Contents

Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

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

Organizational changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Transfer to the Public Health Service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2National Center for Health Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Supporting activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Public Health Conference on Records and Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3National Association for Public Health Statistics and Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Developmental activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Model Vital Statistics Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5U.S. standard certificates and reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Registration areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Improvement of data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Tests of birth registration completeness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Query programs for improving birth and death data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Current Mortality Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Cause-of-death classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Comparability studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Ranking causes of death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Automated mortality data system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Electronic registration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Multiple causes-of-death statistics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Race and ethnicity data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Fetal death and induced termination of pregnancy data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Linked birth/infant death data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Special projects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Vital statistics rates in the United States: 1940–60 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Vital and health statistics monographs, 1959–61 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Cooperative developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Vital statistics component of the Cooperative Health Statistics System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19State centers for health statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Supplemental data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Follow-back surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21National Survey of Family Growth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22National Death Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Availability of vital statistics data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Public-use data tapes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24CD-ROM with SETS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Vital statistics in the 21st century: A vision for the future. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

v

Appendixes

I. Appendix tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

II. History and Organization of the Vital Statistics System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

vi

U.S. Vital Statistics System

Major Activities and Developments: 1950–95

Preface

The early history of the vital statistics system waspresented in detail in Vital Statistics of the UnitedStates, Volume I, 1950. This earlier document isreprinted in this publication in appendix II. Thatreport begins with the early collection and preserva-tion of registration records as legal evidence of theoccurrence of the event, primarily for use in protectingindividual rights. It then describes the era in whichdeath records by cause became recognized as essentialfor control of epidemics and for other public healthinterests. The report goes on to cover how welfarelegislation of the 1930’s and emergency World War IIlegislation of the 1940’s brought about an unprec-edented demand by individuals for their birth certifi-cates.

Included in the earlier report is a description ofthe long, hard-fought, and often discouraging cam-paign of individuals, associations, and State and Fed-eral agencies to bring about uniform registration lawsand reporting forms that could not only serve theincreasing needs of individuals for their records butalso provide data for statistical analysis at all levels ofgovernment. The establishment, development, andcompletion of the registration areas designed to pro-vide national birth and death statistics and the earlyefforts that ultimately led to establishment of similarregistration areas for providing marriage and divorcedata are described. The report traces the Federalfunction in vital statistics from its origin in the Bureauof the Census to its placement in the National Office ofVital Statistics in the Public Health Service in 1946.

The purpose of this report is to pick up where the1950 report ended and describe further developmentsand major activities and accomplishments that occurredfrom 1950 through 1995. Most of the informationincluded was obtained from or based upon materialcontained in government reports. Material from the1950 report is repeated in certain instances to providean informative context for understanding the morerecent developments. Reference is also made to somepre-1950 activities and achievements that were notdiscussed in the earlier report.

All publications that were reviewed by the authorin preparing this report are referred to in the text orcited as sources. Because the publications reviewedare in the public domain, much of the material in themis widely used, appears in numerous publications, andconsequently, is likely to appear in publications notcited in this report.

Introduction

Vital statistics for the United States are obtainedfrom the official records of live births, deaths, fetaldeaths, marriages, divorces, and annulments. The offi-cial recording of these events is the responsibility ofthe individual States and independent registrationareas (District of Columbia, New York City, and terri-tories) in which the event occurs; the Federal Govern-ment obtains use of the records for statistical purposesthrough a cooperative arrangement with the respon-sible agency in each State.

Since 1950 attention has been focused on improv-ing the quality of vital statistics and making themmore useful and widely available. Interest in vitalstatistics widened when State and Federal agencies,challenged to define needs for and effects of variousState and Federal health and welfare programs, beganlooking for pertinent and reliable statistics on which tobase judgments. The registration certificates assumednew importance as they were looked to as a source ofcredible national vital and health statistics for use byall levels of government, institutions, and the generalpublic.

Demand for this information increased, andresearch was undertaken to determine the most eco-nomical and effective application of the rapidly devel-oping data processing technology. Updating datacollecting, recording, and processing techniques to keepabreast of rapidly evolving automation capabilitiesbecame an increasingly important part of the vitalstatistics program.

As health and social issues became more complex,the content of the information collected on the vitalrecords was expanded and measures to improve its

1

2 Major Activities and Developments

quality and usefulness were added. Supplemental datasources were developed to augment and enrich theinformation obtained from the registration system.

The function of producing national vital statisticswas shifted several times from one organizational unitof the Federal Government to another, the most conse-quential being its merging with the National HealthSurvey to form the National Center for Health Statis-tics (NCHS). The following is a discussion of the mostprominent milestones in the progress of the nationalvital statistics program during the last half of the 20thcentury.

Organizational changesThe act of Congress that made the Bureau of the

Census a permanent full-time agency of the FederalGovernment in 1902 also gave the Bureau statutoryauthority to establish registration areas to producenationally comparable vital statistics. This put intomotion the development of a system for the annualcollection of vital statistics data on a national basis.

Transfer to the Public Health Service

These collection activities continued in the Divi-sion of Vital Statistics of the Bureau of the Censusuntil July 1946. At that time the Bureau of the Bud-get’s recommendations of 1943 were adopted, and theFederal Security Administration (one of the agenciesthat was combined with others to form the Depart-ment of Health, Education, and Welfare in April 1953)was given authority for Federal functions in vitalstatistics. The National Office of Vital Statistics wasestablished in the Public Health Service, with thehead of the office reporting directly to the SurgeonGeneral.

National Center for Health Statistics

In 1960 the National Office of Vital Statistics wasmerged with the National Health Survey to establishthe National Center for Health Statistics (NCHS).Effective in September 1963, NCHS was reorganized,with the Division of Vital Statistics becoming one offive operating divisions. This reorganization separatedsupport activities, such as data processing and publi-cation activities, from the substantive vital statisticsprogram operations.

Dr. Forrest E. Linder, the first director of NCHS,articulated the widely held expectations for the newlyestablished center in his comments at the Public HealthConference on Records and Statistics held in 1962. Heenvisioned the center as ‘‘not just a factory, but ascientific organization,’’ the existence of which wouldpermit greater emphasis on analysis as opposed to

mere collection and dissemination of statistics. Hold-ing it to be essential to protect the integrity of NCHSstatistics by distinguishing analysis from propagandaor a program for promotion of solutions to problems,he looked to analysis to identify and clarify problemsthat needed solution.

Dr. Linder saw the center as providing emphasison methodological research in all areas of concern tohealth statistics. This included registration methodsfor vital events, extended relations with the States,more research into operational techniques, and leader-ship in new areas of data collection, follow-back sur-veys, and the gathering of institutional data. Hewelcomed the enlarged relationships made possible bythe center, including intergovernmental cooperation,international exchanges, and collaboration with uni-versities, survey centers, and health organizations.

The Health Services Research and Evaluation andHealth Statistics Act of 1974 (Public Law 93–353)established NCHS in law and codified its mandate andauthorities under section 306 of the Public HealthService Act. The Act provided for NCHS to collectstatistics on a broad range of health-related subjects,including births, deaths, marriages, and divorces. Itestablished the National Committee on Vital and HealthStatistics as an expert advisory committee to theSecretary of the Department of Health, Education,and Welfare. It called for the center to undertake andsupport research demonstrations and evaluationsregarding survey methods and to provide technicalassistance to State and local jurisdictions. Subsequentchanges in public laws that established, amended, orextended NCHS authorities did not substantially affectthe national vital statistics system.

Supporting activities

The history of vital statistics is interlaced withsupportive endorsements and activities of numerousassociations and organizations. From the earliest daysof their existence, the American Statistical Associa-tion, the American Medical Association, the AmericanPublic Health Association, and the American Bar Asso-ciation provided strong support for establishing officesto collect vital statistics. These organizations pro-moted uniform registration laws for vital events, uni-formity in the content of vital records, and an aggressivepublic health program with vital statistics as a princi-pal component. Their interest and influence continue, asthey maintain close relationships with State and Federalactivities bearing on the vital statistics program.

In the late 1940’s, a report published by theNational Bureau of Economic Research on ‘‘The Statis-tical Agencies of the Federal Government’’ validatedthe earlier work of these organizations. The study wasproduced as part of the work of the Commission on

Major Activities and Developments 3

Organization of the Executive Branch of Government,which had been appointed by President Hoover. Thiscommission recommended a new status for the statis-tical activities of the Federal Government, urging highpriority for them among the basic functions of govern-ment and emphasizing the need for budgetaryresources, training and Federal-State coordination toobtain high-quality, comprehensive, and timely statis-tics. It reinforced the findings and recommendations ofthe various organizations and government agenciesthat during the 1930’s and 1940’s had been voicing thesame concerns.

The report presented specific findings and recom-mendations pertaining to the statistical activities ofthe Federal Government. Many were particularly appli-cable to public health statistics. Foremost among thesewas the recommendation that ‘‘appropriate divisions ofthe Public Health Service [will] be responsible for therepetitive collection of natality, mortality, and morbid-ity statistics (which should be part of a unified collec-tion program) and for specialized research, analysis,and statistical testing in this field.’’

The report also urged exploration of means ofcoordinating and unifying the statistical reporting sys-tems of Federal and State governments; recognition ofthe need for recruitment of high-grade statistical per-sonnel; and close liaison between statistical agenciesand respondent and user groups. Bearing on the integ-rity of health statistics was the recommendation thatthe functions of fact finding be ‘‘clearly distinguishedfrom activities involving the setting of social goals orthe promotion of special aid programs.’’

Public Health Conference on Recordsand Statistics

The Public Health Conference on Records andStatistics (PHCRS) was established to develop andcoordinate registration and statistical practices amongState registration areas with the cooperation of theNational Office of Vital Statistics. This office had itsbeginnings in 1935 when the Division of Vital Statis-tics, then in the Bureau of the Census, was mandatedto promote a cooperative system of vital records andvital statistics. With Halbert L. Dunn, M.D., as theprincipal initiator and organizer, the division beganconvening annual meetings of State registration execu-tives and Federal representatives to assess registra-tion problems and to develop and promote solutions.These annual work conferences, restricted to a geo-graphically representative committee during the waryears, proved fruitful and were continued after thewar.

In May 1949, the PHCRS was formally establishedon a permanent year-round basis as a State-Federalorganization sponsored by the National Office of Vital

Statistics, which had by then been established in thePublic Health Service. This brought together the skillsand experience of State registrars, vital statisticians,and public health statisticians in a joint effort with theNational Office of Vital Statistics to improve registra-tion of vital events and the statistics derived from theregistration records.

The conference carried on much of its work throughtwo committees, one on registration and one on statis-tics. All members, according to their choice, served onone of these two committees. Each committee wasdivided into subcommittees as needed to explore andmake recommendations on specific subjects. Over theyears the committee on registration addressed suchissues as confidentiality of records, periodic revision ofthe standard certificates, a model law, completeness ofvital registration, marriage and divorce registration,record linkage, and interchange of nonresident birthand death certificates. Issues addressed by the commit-tee on statistics included national morbidity reporting,multiple causes-of-death tabulations, improvement ofmedical certification, residence allocation, and fetaldeath reporting.

From 1958 until his retirement in 1973, Junior K.Knee, Assistant to the Director, NCHS, served asexecutive secretary of the PHCRS. Under his activeleadership, the PHCRS was a strong influence inpromoting local-State-Federal cooperation. In additionto working toward increased accuracy and complete-ness of vital records, he was a strong advocate ofbalancing the attention given to the essential legalpurposes of the documents with that given to theirpotential to provide information not available else-where for analysis of public health problems.

Currently, the PHCRS is a biennial meeting spon-sored by NCHS. It focuses on health statistics relatedto emerging public health issues. Its sessions addressdata needs and issues related to data quality andintegrity, methodological aspects of measuring andevaluating health care needs and services, appropri-ateness of various measures, improving data reliabil-ity and validity, data collection and analytic issues,new developments in information and data handlingsystems, and other pertinent and timely topics as theyarise.

National Association for Public HealthStatistics and Information Systems

The National Association for Public Health Statis-tics and Information Systems (NAPHSIS) was orga-nized in 1933 and was first known as the AmericanAssociation of State Registration Executives. Asdescribed in its 50th anniversary history (1), the statedpurpose of the association was ‘‘to study and promoteall matters relating to the registration of vital statis-


tics.’’ The members were ‘‘all persons in active execu-tive charge of the registration of vital statistics in astate department and persons holding similar posi-tions in Canada, Mexico, and Cuba. The Chief Statis-tician for Vital Statistics of the United States Bureauof the Census shall be a member ex-officio.’’

The association has undergone several namechanges. In 1938 the name was changed to the Ameri-can Association of State and Provincial RegistrationExecutives. In 1939 it was changed to the AmericanAssociation of Registration Executives (AARE), and in1958, the name became the American Association forVital Records and Public Health Statistics (AAVR-PHS). In 1980 it was changed to the Association forVital Records and Health Statistics (AVRHS). In 1995the name became the Association for Public HealthStatistics and Information Systems (APHSIS) and in1996, the National Association for Public Health Sta-tistics and Information Systems (NAPHSIS). Theselater changes reflect the broadening interests of theassociation.

Similarly, the stated purpose of the associationalso changed over the years. Until 1950, it continuedto be ‘‘to study and promote all matters relating to theregistration of vital statistics.’’ In 1950, it became ‘‘towork for the development and maintenance of soundsystems of vital records that can provide the informa-tion and services needed in the best interest of thepeople and their government.’’ In the 1958 revision ofthe bylaws, the purpose of the association read ‘‘toprovide opportunity for discussion of and group actionon problems and policies involved in the administra-tion of vital records and public health statistics pro-grams in the United States, its territories andpossessions, and to serve as an advisory group to theAssociation of State and Territorial Health Officers forthe programs.’’ The last sentence of the purpose wasamended in 1982 to read ‘‘. . . to serve as an advisorygroup to the Association of State and Territorial HealthOfficials (ASTHO) and other organizations for theseprograms.’’ The 1995 revision of the association bylawsstates: ‘‘This Association will foster discussion andgroup action on issues involving public health statis-tics, public health information systems, and vitalrecords registration. The Association will provide stan-dards and principles for administering public healthstatistics, public health information systems, and vitalrecords registration. The Association will represent theStates and Territories of the United States regardingthese issues, and will serve as an advisory group to theAssociation of State and Territorial Health Officials.’’

The association also widened eligibility for mem-bership as its interests grew. In 1938 it expandedmembership to include ‘‘all persons in active executivecharge of the registration of vital statistics in Stateand provincial departments in the United States andPossessions, Canada, Mexico, Cuba, New York City,

Baltimore, and Washington, DC.’’ In addition to theChief Statistician for Vital Statistics of the UnitedStates, it included as ex-officio members the assistantstatistician and officials holding similar positions inCanada, Mexico, and Cuba. It also provided for lifemembership for members who served for 20 years as aregistration executive. The 20-year requirement wasdropped in the 1950 bylaws. In 1946, Boston and NewOrleans were added to the list of included independentregistration areas.

In 1950 the association established a governingcouncil comprised of the association membership asdefined in 1946. The right to hold office, to serve onstanding committees, and to chair other committeeswas limited to members of the governing council.Concurrently, persons professionally engaged in vitalrecords work were eligible for election to membership,and individuals or corporations interested in vitalrecords were eligible for sustaining membership byvote of the executive board. In 1958 sustaining mem-berships were dropped and an associate membershipwas established for ‘‘persons professionally engaged invital records or public health statistics programs inState or local health departments.’’

In 1982 the membership categories included gov-erning council members, associate members, and hon-orary life members. With the 1995 revision of theassociation bylaws, different membership categorieswere established. Agency-designated members includeState, territorial, and local health departments orother non-Federal Government agencies; these mem-berships entitle the designation of up to four salariedstaff persons of the organization. Individual member-ships may be purchased for additional agency staff,including local health department staff who are profes-sionally engaged in public health statistics and infor-mation systems, and affiliate (nonvoting) membershipsare open to persons not eligible for voting membershipwho are interested in furthering improvements topublic health statistics and information systems. Theright to hold office and to attend special closed sessionsfor voting members only is limited to agency-designated and individual members. Any member mayserve on association committees.

The 1958 revision of the bylaws was preceded by arequest of the Association of State and TerritorialHealth Officers (ASTHO) for an evaluation of thefunctions and relationships of the American Associa-tion of Registration Executives (AARE) and the PublicHealth Conference on Records and Statistics (PHCRS).As a result of that request, the Joint Committee onVital Records and Health Statistics was established bythe executive committees of the AARE and the PHCRS.

At its first meeting, the joint committee discussedand reached tentative agreement on the aims andobjectives of public health records and statistics andhow they might be achieved. At subsequent meetings


the joint committee drafted proposals for reorganizingthe AARE and reconstituting the PHCRS into a studyprogram; submitted the proposals for review by mem-bers of the AARE and the PHCRS; and after consider-ing the comments received, prepared and submittedfinal proposals. This added to the existing cooperationin programs between the PHCRS and the AARE andmoved the AARE toward expanding its objectives andmembership to include both registration and statis-tics. The 1958 revised bylaws provided the delineationof objectives and reflected the broadened scope ofactivities sought by ASTHO.

The association’s sphere of interest and influencehas continuously expanded. In 1956 at the suggestionof the statistics section of the American Public HealthAssociation (APHA), the AARE joined it in a coopera-tive relationship that led to such joint activities asco-sponsored sessions at the national APHA annualmeetings.

The association continues to be the link betweenthe registration areas and the Federal Government inpromoting complete registration of vital records andproducing from them uniform, accurate, and usefulstatistics. It has assumed the special function of rep-resenting the collective viewpoint of the registrationareas in Federal-State relationships. Its strong influ-ence is felt in all matters pertaining to the collectionand dissemination of vital and health statistics at thelocal, State, and Federal levels. The association, as itscurrent name (National Association for Public HealthStatistics and Information Systems) implies, will alsobe a voice with other professional associations, theFederal Government, and State governments on publichealth statistics, vital records, and information sys-tems issues.

The association held biennial meetings until 1969,when it began annual meetings. Through 1985, in theyears in which the public health conference was held,the association held its meeting at the same locationimmediately preceding or following the conference,making it possible for its members to attend both.Although this was discontinued, the association con-tinues to hold annual meetings, inviting representa-tives of various Federal agencies. Since 1989, inalternate years the association’s annual meeting hasbeen held jointly with NCHS as part of the VitalStatistics Cooperative Program project directors’ meet-ing. The annual conferences include business meetingsas well as training sessions on current technology,public health information systems, vital record prac-tices, and leadership development.

Although NCHS has been the prime Federal agencywith which the association interacts, it has expandedits relationships with numerous other agencies, includ-ing other components of the Centers for Disease Con-trol and Prevention, the Health Care FinancingAdministration, the Bureau of the Census, the Bureau

of Labor Statistics, the Social Security Administration,and the National Institutes of Health. The associationis an affiliate of the Association of State and TerritorialHealth Officials (ASTHO) and is a member of otherprofessional associations such as the Council of Profes-sional Associations on Federal Statistics (COPAFS).

Developmental activities

The Federal Government, with no express consti-tutional authority to enact vital statistics legislation ofa national scope, depends upon the States to enactlaws and regulations that provide methods of registra-tion and data collection comparable from State toState.

To achieve the uniformity required for combiningdata from all States to provide national statistics,certain standards are recommended by the Federalagency responsible for national vital statistics as guidesfor use by State registration offices. Foremost amongthese are a model State vital statistics act, proposed asa guide for formulating legislation pertaining to regis-tration of vital events, and model forms containingspecified items of information that not only meet thelegal needs of individuals but also provide statisticaldata in a standardized form comparable from onereporting area to another.

Model Vital Statistics Act

The Bureau of the Census submitted the firstmodel bill to the States in 1907, covering both birthand death registration. It provided for forms to includeas a minimum the items recommended by the Bureauof the Census. Numerous revisions of both the modellaw and the recommended forms have followed. Thedevelopment, periodic review, and revision of the rec-ommended standards became an essential function inobtaining comparable data from State and local regis-tration offices for producing national vital statistics.Responsibility for this function was transferred fromthe Bureau of the Census to the U.S. Public HealthService in 1946 and now rests with the Division ofVital Statistics in NCHS.

In response to the expressed needs of State execu-tives and Federal agencies, a new Model State VitalStatistics Act was tentatively approved in 1940 andadopted in 1942 (U.S. Bureau of the Census, 1941).For the first time, the Model Act gave a statutorydefinition of vital statistics, defining them as ‘‘theregistration, preparation, transcription, collection, com-pilation, and preservation of data pertaining to thedynamics of the population, in particular, data pertain-ing to births, deaths, marital status, and the data andfacts incidental thereto.’’ This was the first inclusion ofmarriages and divorces in the model legislation per-


taining to vital statistics. This revision also includedthe first provision for a standard certificate of still-birth, discarding the making of a birth and a deathcertificate to cover a stillbirth. It declared vital statis-tics records to be public records but restricted the rightof public inspection.

The increasing demand for reliable certified copiesin the 1940’s gave added importance to registrationand uniformity in forms and consequently to the ModelAct and its recommendations.

The Model State Vital Statistics Act was revised in1959 (U.S. Department of Health, Education, andWelfare, 1960). This revision was not an abrupt depar-ture from earlier model vital statistics acts but ratherone in a series of revisions carried out periodically tokeep the Model Act current with changing demandsupon State vital records systems.

More substantive changes were made in the ModelAct in 1977 (National Center for Health Statistics,1978). This revision provided for a centralized systemin each State for the collection, processing, registra-tion, and certification of vital records in which all vitalevents are reported directly to the State office of vitalstatistics. It placed the local offices under the directcontrol of the State registrar and gave the Stateregistrar the option to direct local offices to performany of those functions when it was in the interest ofefficient and effective service. The 1977 revision alsomade a significant change in the registration of fetaldeaths, changing the reporting instruments to statis-tical reports to be used only for medical and healthpurposes, as opposed to permanent official records ofthe system of vital statistics. Modifications were addedto provide for filing birth certificates for foreign-bornchildren adopted by citizens in the State where theyare adopted. This revision gave special attention toprivacy concerns, confidentiality, and fraudulent use ofvital records, and strengthened penalty provisions ofthe Model Act as a deterrent to illegal use of vitalrecords.

Model State vital statistics regulations were firstissued in 1973 (National Center for Health Statistics,1973). It was recommended that both the Act andregulations be considered when a State modifies itsvital statistics statutes. The purpose of the regulationswas to augment the Model Act and to standardizemany of the administrative practices and proceduresin effect in vital statistics offices. Consistency amongStates in day-to-day administrative procedures hasbeen found to improve the uniformity essential fornational statistics. The model regulations have beenrevised in conjunction with all subsequent revisions ofthe Model Act.

The 1992 revision of the Model Act and regulations(National Center for Health Statistics, 1994) was under-taken with the intention of producing a practical ratherthan ideal model and one that most States could adopt

with few modifications. The intent was to develop amodel that was flexible enough to accommodate newtechnologies that are sure to evolve for the collection,storage, and retrieval of vital records. The Act specifi-cally allows for the electronic production and transmis-sion of vital records. It also removed the requirementsfor signatures except where the requirement relates toan affidavit.

Provisions of the Model Act concerned with confi-dentiality and security of vital records were strength-ened. Several issues regarding vital records wereaddressed for the first time as the result of changes insocietal attitudes and practices. For example, guid-ance is provided on the naming of the father, and insome instances the mother, on birth records involvingartificial insemination, in vitro fertilization, and sur-rogate parenthood.

The Model Act recommends to the States that theintegrity of vital records and reports be protectedthrough reasonable control of the use of such records,restricting disclosure of information that can identifya person or institution named in any vital record orreport. It further recommends that Federal agenciesand researchers who are furnished copies of suchrecords be required to enter into agreements thatprotect the confidentiality of the information provided.The intent is to encourage legitimate and appropriateuse of the records for statistical and administrativepurposes, while protecting individuals from an unwar-ranted invasion of privacy.

U.S. standard certificates and reports

The U.S. standard certificates and reports issuedas models for the States and independent registrationareas to use in developing their registration forms arereviewed periodically to ensure that they meet theirintended uses at the local, State, and national levels.Persons involved in the registration and statisticalprocesses at all levels of government are involved inthe review. The opinions of major users of the data arealso sought. Revisions are made to reflect changingconditions and user needs. The U.S. standard certifi-cates and reports are currently an integral part of theVital Statistics Cooperative Program through whichNCHS obtains data to produce national vital statistics.They contain the minimum basic data set to meetcontract requirements.

There have been 11 issues of the Standard Certifi-cate of Live Birth; 10 of the Standard Certificate ofDeath (in 1915 the birth certificate but not the deathcertificate was revised); 7 of the Standard Report ofFetal Death (formerly Stillbirth); 4 of the StandardCertificate of Marriage and the Standard Certificate ofDivorce, Dissolution, or Annulment; and 2 of the Stan-dard Report of Induced Termination of Pregnancy.


Most of the additions and deletions from one revisionto another resulted from changing perceptions as tothe usefulness of the items in question in meeting theincreasing needs for information.

Before 1937, birth and death statistics publishedfor States, counties, and cities were by place of occur-rence. Beginning with data for 1937, most of thegeographic tabulations were changed to place of resi-dence. The need for complete and accurate residenceinformation influenced the redesign of the certificates.

The number of items on the birth certificateincreased from 33 in 1900 to 60 in 1989, the mostrecent revision. In recent revisions, most new itemsrelate to information concerning the pregnancy, deliv-ery, and condition of the child.

Similarly the number of items on the death certifi-cate increased from 42 in 1900 to 71 in 1989. Most ofthe new items related to the expanded cause-of-deathcertification introduced in the 1939 revision and toitems concerning the nature and circumstances sur-rounding injuries causing death.

Tables showing the changing content of the vari-ous standard certificates from the first through the1989 revision can be found in appendix I. NCHSpublished three reports describing in detail the stan-dard certificate revisions of 1968 (2), 1978 (3), and1989 (4).

U.S. standard certificates of birth, death,and fetal death

In the early years, few changes were made in thecontent of the U.S. standard certificates of birth anddeath. For the death certificate, the most noteworthywere the addition of autopsy information in the 1918revision, provision for information concerning injuriesfrom external causes of death in the 1930 version, andrevision of the cause-of-death portion of the certificatein 1939. Also in 1939, the Social Security number andmore detailed information on place of residence of thedeceased were added.

Early expansion of the birth certificate also wasgradual. Prior to the 1930 revision, the certificatecontained place of birth, identifying information per-taining to the child, and occupation for both the motherand father. Also included were variations of itemsconcerning number of children born to this mother,now living, now dead, and born dead. In the case ofstillbirth (the delivery of a product of conception thatdoes not show evidence of life after the delivery), botha birth and death certificate were required to be filed.In the 1930 revision of the Standard Certificate of LiveBirth, items relating to stillbirth were added (period ofgestation, cause of stillbirth, and whether before laboror during labor). In 1939 more detailed informationconcerning residence of the mother was added.

In the 1949 revision, both the death certificate andthe birth certificate were reformatted. The section

containing the medical certification of cause of deathwas placed on the lower half of the death certificateand a section labeled ‘‘For Medical and Health UseOnly’’ was added to the bottom of the birth certificate.The latter contained the items on length of pregnancy,legitimacy, and an added item on weight at birth. Therevised format made possible omission of this personalinformation from certified copies of the certificates. Anitem on citizenship of the deceased was added to thedeath certificate in 1949 but was dropped in 1989. Alsoadded was an item indicating whether the decedentwas ever in the U.S. Armed Forces. That item wasdropped in 1968 but reinstated in 1978. Although onlyminor changes were made in the content of the deathcertificate between 1939 and 1989, substantive revi-sions were made in the birth certificate.

Beginning with the 1939 revision, the birth certifi-cate became the Standard Certificate of Live Birth,and in 1955 the Certificate of Fetal Death was requiredfor stillbirths. In subsequent revisions, the content ofthe certificate for fetal deaths followed closely thecontent of the birth certificate, except for the additionof sections containing cause-of-death and burial infor-mation. In the 1978 revision, the title was changed toU.S. Standard Report of Fetal Death to reflect thenature of the document as a statistical report ratherthan a certificate to be filed permanently.

In 1968 items added to the birth certificate andfetal death report were education of mother and father,date of last live birth and of last fetal death, date lastnormal menses began, prenatal care, complicationsrelated and not related to pregnancy, complications oflabor, congenital malformations or anomalies of child(or fetus), and birth injuries to child (or fetus). Theseitems expanded the section containing confidentialinformation for medical and health use only.

In 1978 the Apgar score was added to the confiden-tial section of the birth certificate. On both the birthcertificate and the fetal death report, a question onwhether the mother was married replaced the item onlegitimacy. Also on both, an item for specifying concur-rent illnesses or conditions affecting pregnancy replacedthe item for complications not related to pregnancy.

In the 1989 revision, major changes were made inthe content and format of the live birth certificate andthe fetal death report. Both forms were increased insize to make room for detailed medical and healthinformation about the mother and child or fetus. Check-boxes were added for these items to simplify comple-tion of the forms and improve the quality of reportingof information useful in studies of newborns. Check-boxes were also added to both for clarity, to providespecific information concerning the attendant, and onthe birth certificate, for information about place ofbirth and the certifier. It was anticipated that elec-tronic filing of certificates would negate the need forlarge paper documents.


Among the added items providing medical andhealth information on both the certificate of live birthand the report of fetal death were items indicatingspecific complications of labor and/or delivery andspecific congenital anomalies of child or fetus. Itemswere also provided on both to obtain for the first timeinformation on obstetric procedures, risk factors forthe pregnancy (medical and other, including maternaluse of tobacco and alcohol, and weight gain), method ofdelivery, and for live births, abnormal conditions of thenewborn. Items were added to the fetal death report toindicate the occupation and business or industry inwhich the mother and father worked during the lastyear, reflecting interest in the effect on the fetus ofwork-related environmental exposure. Although notadded to the birth certificate, States were encouragedto collect and code these items for births if resourcespermit. This body of information facilitates analyses ofinterrelationships among specified risk factors, compli-cations of pregnancy, obstetric procedures, and deliv-ery methods, and fetal and infant mortality.

The certificate of death was also enlarged in the1989 revision. Additional space was provided for themedical certification section. Space was added for morecomplete reporting of conditions that describe thechain of events leading to death and of other signifi-cant conditions contributing to death. Detailed instruc-tions for selected items, including an example forcompleting the medical certification, fill the back of thecertificate. The three separate alternative certificatesintroduced in 1968 (one for use by physicians, one formedical examiners or coroners, and one suitable foruse by both physicians and medical examiners orcoroners), were replaced by one for use by all certifiers.The single certificate is believed adequate to meet theneeds of most States and, if required, is easily modified.

An item was added to the death certificate forreporting the decedent’s education, useful as an indi-cator of socioeconomic status and a factor in mortalitydifferentials. Another item was added to indicatewhether autopsy findings were used in determiningcause of death. The item on manner of death wasreworded to include checkboxes. Two items, country ofcitizenship and name of attending physician if otherthan certifier, were dropped.

A Hispanic identifier was added for the motherand father on the certificate of live birth and the reportof fetal death. It was also added for the decedent onthe certificate of death, and for the patient on thereport of induced termination of pregnancy.

U.S. standard report of induced terminationof pregnancy

In January 1973, the U.S. Supreme Court ruledthat the restrictive abortion laws in two States wereunconstitutional and that, within the first two trimes-

ters of pregnancy, whether an abortion was to beperformed or not was a matter between the womanand her doctor ( Roe v. Wade, 410 U.S. 113 (1973); andDoe v. Bolton, 410 U.S. 179 (1973)). The net result ofthe rulings was that induced abortion under thesecriteria became legal in all States. Because of theimpact of abortion on fertility and the need for healthand demographic data about these procedures, theneed for a uniform reporting system was soon recog-nized. Data needs and reporting requirements forinduced terminations differ from those for spontane-ous fetal death. Consequently, separate forms wererecommended.

The 1978 version of the U.S. Standard Report ofFetal Death was recommended for the collection ofdata on spontaneous fetal deaths at 20 weeks of gesta-tion and over. A new form, the U.S. Standard Report ofInduced Termination of Pregnancy, was recommendedfor reporting all induced terminations of pregnancyregardless of length of gestation. Unlike the fetaldeath report, this form does not include the name ofthe woman having the abortion. Among the itemsincluded on the induced termination of pregnancyform were facility name and location, age of patient,whether married or not, date of pregnancy termina-tion, residence, race, education, previous pregnancies,type of termination procedures, complications of preg-nancy termination, date last normal menses began,physician’s estimate of gestation, name of attendingphysician, and name of person completing report. Inthe 1989 revision, an item on dilation and evacuationwas added to the list of termination procedures. Theitem asking for complications of pregnancy termina-tion was deleted because of underreporting, as mostcomplications are not evident until after the report hasbeen filed.

In 1995 the Division of Reproductive Health inCDC took the lead to revise the list of terminationprocedures on the Standard Report of Induced Termi-nation of Pregnancy. The impetus for this action wasthe need for one or more categories to identify medicalmethods used for terminating a pregnancy.

U.S. standard certificates of marriage anddivorce, dissolution of marriage, or annulment

The first Standard Record of Marriage and Stan-dard Record of Divorce or Annulment were recom-mended to the States for implementation on January1, 1955. The recommended Standard Record of Mar-riage included the following information concerningboth bride and groom: name, place of residence, dateand place of birth, previous marital status (and ifpreviously married, the number of marriages and howthe last marriage ended), race, usual occupation, kindof business or industry, signature of applicants, anddate signed. Certification information included date


and place of marriage, date of recording, and signatureand title of officiant.

The recommended Standard Record of Divorce,Dissolution of Marriage, or Annulment included thefollowing information concerning both husband andwife: name, place of residence, date and place of birth,number of marriage being dissolved, race, occupation,and kind of business or industry. Decree informationincluded place and date of marriage being dissolved,number of children under 18, plaintiff, party to whomdecree was granted, legal grounds for decree, date ofdivorce, date of recording, and signature and title ofcourt official.

In the 1968 revision of the standard certificates,the titles of the records were changed to U.S. StandardCertificate of Marriage and U.S. Standard Certificateof Absolute Divorce or Annulment. A section for confi-dential information was added to both the marriageand the divorce certificates. Items added to the mar-riage certificate were identification of the officiant asreligious or civil, education, and for the previouslymarried, date last marriage ended. Items added to thedivorce certificate were approximate date couple sepa-rated, name of attorney for plaintiff, number of previ-ous marriages ended by death or divorce or annulment,and the total number of living children as well as thenumber under 18 years of age.

In the 1978 revision, the heading of the marriagecertificate was changed to U.S. Standard License andCertificate of Marriage. The recommendation com-bined in one form both the license and the certificatein order to reduce the workload and number of formsrequired of the local official responsible for marriageregistration.

Changes made in the content of the 1978 and 1989revisions of the marriage and divorce certificates wereminor. They consisted mainly of changes in terminol-ogy to clarify intent of certain items. In 1989 type ofceremony was deleted from the marriage certificateand number of children ever born alive of this mar-riage was deleted from the divorce certificate. Added tothe divorce certificate was an item to indicate thenumber of children under 18 whose physical custodywas awarded to husband, wife, joint husband and wife,or other.

Registration areas

The first birth and death statistics published bythe Federal Government for the entire United Stateswere based on information collected during the 1850decennial census. Similar collections were made dur-ing each decennial census up to and including thecensus of 1900. These reports were inaccurate andincomplete, and it became evident that reliable datacould be obtained only from States and large cities

that had efficient systems for the registration of theseevents.

In 1880 the Bureau of the Census established anational ‘‘registration area’’ for deaths. It consisted oftwo States, Massachusetts and New Jersey, the Dis-trict of Columbia, and several large cities innonregistration-area States. Those were the areas thatcould provide adequate statistics. By 1900 eight addi-tional States had been admitted and the annual collec-tion of mortality statistics for the registration area hadbegun. Each area had been requested to adopt therecommended death certificate and model law andobtain 90 percent completeness of registration. Theregistration area gradually increased as more Statesenacted and enforced laws requiring the registrationof deaths. Beginning with 1933, all 48 States and theDistrict of Columbia were included.

It was more difficult to obtain accurate and com-plete registration of births than it was for deaths. Thenational birth-registration area was not establisheduntil 1915. Admission requirements were similar tothose for deaths. The birth-registration area included10 States and the District of Columbia. As with thedeath-registration area, all 48 States and the Districtof Columbia had been admitted by 1933. Alaska wasadded to both registration areas in 1959 and Hawaii in1960, the years in which they gained statehood.

The early collections of national marriage anddivorce statistics began in 1940. These consisted ofnumbers or estimated numbers of marriages anddivorces collected from each State. Detailed statisticswere collected and published for both events for Statesable to submit transcripts of records or statisticaltables from which data could be consolidated.

The marriage-registration area (MRA) was estab-lished in 1957. It included 30 States, Alaska, Hawaii,Puerto Rico, and the Virgin Islands. New York, countedas one of the 30 States, excluded New York City. In1979 the MRA reached its peak and included 42 States,the District of Columbia, Puerto Rico, and the VirginIslands.

The divorce-registration area (DRA) was estab-lished in 1958. It was made up of 16 States and theVirgin Islands. The DRA reached its peak in 1986 andconsisted of 31 States, the District of Columbia, andthe Virgin Islands.

To be admitted to the marriage- and divorce-registration areas, States were required to establishcentral State files for collecting copies or abstracts ofthe records, to adopt a statistical report conformingclosely in content to the U.S. standard certificates, tomaintain regular and timely reporting to the Stateoffice by all local areas in which marriages or divorcesare recorded, and to agree to tests of completeness andaccuracy in cooperation with NCHS. Registration ofevents and reporting of required items were expectedto be at least 90-percent complete. Three States, Ari-


zona, New Mexico, and Oklahoma, did not have cen-tral files of marriage records. The same three Statesplus Indiana did not have central files of divorcerecords.

The MRA and DRA, patterned after the registra-tion areas used successfully to promote birth anddeath registration, were never completed. In 1995 theMRA included 45 registration areas and the DRAincluded only 33. From 1957 and 1958, respectively, to1995, NCHS obtained detailed marriage and divorcedata from States in the MRA and DRA. However, thisprogram ended with data year 1995, when Federalresource constraints forced NCHS to set priorities fordata within the National Vital Statistics System.Although the importance of marriage and divorce datawas widely recognized, it was also evident that infor-mation could be obtained from other sources, includingthe Bureau of the Census Current Population Survey.Consequently, NCHS made the decision to reduce thescope of the marriage and divorce components of theNational Vital Statistics System, thereby ensuring thecontinued viability of the remainder of the system. Asof January 1, 1996, NCHS began to collect and publishonly monthly counts of the marriages and divorcesregistered in each State.

Improvement of data

Efforts to improve the quality and usefulness ofvital statistics began with the first collections of dataand are still very much a part of the vital statisticsprogram. They include testing for completeness andaccuracy of data, querying incomplete or inconsistententries on records, updating classifications, improvingtimeliness and usefulness of data, and keeping pacewith evolving technology and changing needs for data.

Tests of birth registration completeness

The completeness of the registration of births waslong a subject of concern. Early in the 20th century,States and local areas began investigations into under-registration of births. Some compared records of infantdeaths or lists of children in school with birth records.Others sent postal cards to every household (or to asample of households) in the State, requesting a reportas to whether a child had been born during a specifiedtime period. These investigations varied greatly fromState to State both in methodology and quality. As aresult, their findings could not be combined to provideestimates of underregistration of births for the entirecountry.

The first birth registration test to provide nationalestimates of underregistration of births, based on uni-form data from all States for the same time period,was carried out in connection with the 1940 decennial

census. It was accomplished through the joint effortsof the Bureau of the Census (which then had respon-sibility not only for taking the census but also for theannual collection of vital statistics data) and the State,territorial, and independent city registration offices.This test gave percent estimates of the completeness ofbirth registration for the United States, each State,county, and incorporated city or urban place having apopulation of 10,000 or more in 1940 and that part ofeach county outside of the cities or urban places of10,000 or more (5).

A second such test was conducted in connectionwith the 1950 decennial census under the same aus-pices, except by then the responsibility for nationalvital statistics data had been transferred to the PublicHealth Service and placed in the newly establishedNational Office of Vital Statistics.

In both of these studies, copies of birth certificatesobtained from State offices of vital statistics werematched against records obtained from the enumer-ated population of the respective decennial censuses.Special records prepared by census enumerators for allinfants alive on April 1 who had been born duringpreceding months (4 months for the 1940 test and 3months for the 1950 test) were matched with copies ofbirth records for all infants born during the sameperiods. These matches provided information on howmany infants were missed by census enumerators aswell as how many births were not registered. Theyalso pinpointed problem areas by State and localityand provided estimates of underregistration by raceand whether the birth occurred in or out of a hospital.

A third nationwide study of birth registration com-pleteness was based on a sample of births occurringduring the 5 years 1964–68 (6). The actual collection ofbirth information for this study began in June 1969and continued through March 1970. The study wascarried out by the Bureau of the Census with thecooperation of NCHS and the registration offices of theStates and the District of Columbia, and the indepen-dent city registration offices. The major objective ofthis test was to improve the estimates of births used inpreparing independent estimates of population. Forthis purpose the main interest was in national esti-mates by race, a much less costly undertaking thandeveloping estimates for States and local areas. Twocontinuing household surveys were used in the study—the Current Population Survey and the Health Inter-view Survey. The Bureau of the Census is the datacollection agent for these surveys, which use nationalprobability samples obtained by trained interviewers.In these surveys, interviewers completed a specialrecord, referred to as a ‘‘birth card,’’ for each child aliveat the time of the interview who had been born in the5-year interval 1964–68. The birth cards were reviewedfor completeness of demographic information aboutthe child and for items essential for matching pur-


poses. They were then delivered to the State and cityregistration offices, where each card was matched withthe birth certificate for that child. Extensive followupinterviews and additional searching procedures wereconducted as required to maximize matches.

Estimates from this test of completeness of birthregistration indicate that birth certificates are on filefor more than 99 percent of children born during theyears 1964–68, an improvement over the estimates for1950 (98 percent) and 1940 (93 percent).

Query programs for improving birthand death data

In keeping with its role of promoting improvedaccuracy, timeliness, completeness, and uniformity ofdata contained in the official records of vital events,NCHS and its predecessor agencies have provided todirectors of vital statistics offices guidance and assis-tance in the development and implementation of queryprograms.

Over the years querying practices have varied inintensity from State to State and from time to time.Variations included differences in procedures employedto identify problems, proportions of records queried,reasons for queries, timeliness of queries, and resultsachieved by queries.

Currently, the contract between NCHS and indi-vidual States provides for the implementation of queryprograms. NCHS issues instruction manuals to definethe general duties and responsibilities of individualsand institutions involved in the registration process.These manuals provide detailed guidelines for queryprograms and set forth the principles and proceduresessential for complete and accurate registration ofvital events.

A separate manual deals exclusively with cause-of-death queries. As part of the registration process, vitalstatistics offices go back to the certifying physicianwhen additional information is needed to clarify illeg-ible, incomplete, imprecise, or questionable entries; toverify causes attributed to diseases that pose seriousthreats to the health of others; and to facilitate classi-fication of the causes in a manner that ensures thequality of cause-of-death statistics. The query pro-grams serve not only to improve the quality of mortal-ity data and to emphasize their importance for healthand research purposes but also to provide guidance tophysicians on proper cause-of-death certification.

The current manuals are Instruction Manual, Part18, Guidelines for Implementing Field and Query Pro-grams for Registration of Births and Deaths, VitalStatistics and Instruction Manual, Part 20, Cause-of-Death Querying, Vital Statistics, Data Preparation.

NCHS has also developed handbooks and madethem available to the States. The handbooks detail

item by item how to complete birth, death, fetal death,marriage, and divorce records. Handbooks for deathcertificates have been prepared for funeral directors,certifying physicians, and for medical examiners orcoroners. The handbooks were developed with inputfrom officials in State and local vital records offices,where the handbooks are widely used.

Current Mortality Sample

During World War II, concern over the threat ofepidemics and the possibility of a general decline innational health resulting from wartime living condi-tions produced an urgent need for up-to-date mortalitystatistics by cause of death. There were large numbersof young people suddenly brought together and closelyquartered in training facilities, overcrowded housingin cities with rapidly growing defense industries andactivities, longer working hours, strained hospital facili-ties, and shortages of physicians. All these conditionsoffered great potential for severe epidemics of virulentdiseases. The wait of a year or more following theyears in which the deaths occurred before the annualmortality statistics could be made available was nolonger tolerable to public health officials. The Bureauof the Census responded to the challenge by setting upa program for taking a monthly 10-percent sample ofall death certificates received in State vital statisticsoffices. Thus, the Current Mortality Sample (CMS)was established. Theodore D. Woolsey was the leadingadvocate for the development of the CMS, and W.Edward Deming, Ph.D., was the principal advisor onits implementation (7).

The bureau’s sampling program was designed sothat certain statistics on mortality could be compiledon a month-to-month basis with as little as a 2-monthdelay between the month a death occurred and themonth it was included in the published statistics.Funeral directors or medical examiner/coroners wererequired to provide a death certificate to their localregistrar in exchange for a burial permit. In turn, thelocal registrars were required to send the death certifi-cates that they had collected each month to the Statecentral vital statistics office for filing. State officeswere then able to send monthly samples of the deathcertificates to the national office. The monthly ship-ments of death certificates from the local registrarsbegan to arrive in the State offices about the 10th ofeach month, and by the 20th, most of them had beenreceived. In the sampling program, every 10th certifi-cate of those received between two dates a monthapart was selected, copied, and mailed to the Bureauof the Census on the 25th of the month, this being themonth following the month in which most of thedeaths occurred. At the time the selection was made,the certificates were usually in order by registration


districts, thus providing a good geographic distribu-tion of deaths in the sample.

The first data from this sampling program waspublished February 5, 1943, in the first CMS report,which contained statistics for the month of November1942. Comparative data for August, September, andOctober 1942 were also shown, and variation chartsfor selected diseases for each month of the precedingyear were included.

Monthly mortality statistics based on the 10-percentmortality sample are presently published by NCHS intheMonthly Vital Statistics Report (MVSR). Data basedon the sample are published 1 month after publicationof the monthly provisional national and State counts.The provisional counts are the number of events reg-istered in a State during a 30-day period. Prior to1991, no attempt was made to adjust the occurrencecounts to account for differences between occurrenceand resident events. Beginning in 1991, adjustmentratios were applied to each State to obtain estimatesfor births, deaths, and infant deaths by State of resi-dence. The MVSR currently contains much moredetailed statistics and charts than the initial CMSreport, with considerably greater lag time between themonth a death occurs and the month it is included inthe published statistics.

Cause-of-death classification

Causes of death are classified for purposes ofstatistical tabulation according to the InternationalStatistical Classification of Diseases, Injuries, andCauses of Death, published by the World Health Orga-nization. This classification originated as the ‘‘Ber-tillon Classification of Causes of Death,’’ prepared inthe late 1800’s by Dr. Jacques Bertillon, chairman ofthe committee charged by the International StatisticalInstitute with preparation of a classification of causesof death for international use. In 1898 the AmericanPublic Health Association (APHA) recommended thatthe classification be adopted by Canada, Mexico, andthe United States and that it be revised every 10 yearsto keep abreast of advances in medicine. The Interna-tional Statistical Institute accepted the recommenda-tion for decennial revision, and the first revision wasadopted by the United States for use in 1900. To date,there have been 10 revisions of this classification, nowknown as the International Classification of Diseases(ICD). The years for which causes of death in theUnited States have been classified by each revision areas follows:

Revision Years covered

First 1900–09Second 1910–20Third 1921–29

Fourth 1930–38Fifth 1939–48Sixth 1949–57Seventh 1958–67Eighth 1968–78Ninth 1979 to date

As of the end of 1995, the 10th revision had not yetbeen implemented.

Traditionally, a single cause of death has beenselected for statistical tabulations. When the certify-ing physician indicated that more than one causecontributed to the death, a procedure was required forselecting the cause to be tabulated. In the earliesteditions of the international list, the concept of joint-cause classification was evident. Certain principles fordetermining the cause to be tabulated when more thanone cause was reported were incorporated as part ofthe general classification scheme. Application of theseprinciples in the interest of continuity and comparabil-ity soon resulted in the establishment of definite rela-tionships among various conditions represented by therubrics of the international list, indicating which tookprecedence for tabulation as the cause of death.

The desirability of uniform treatment in selectingthe cause of death when more than one cause wasreported intensified with the increase in medical knowl-edge. As diagnostic capabilities improved, multiplecauses were reported more frequently. The result wasa listing of the established relationships in theManualof Joint Causes of Death, first published in 1914 andrevised in 1925 and again in 1933 to conform tosuccessive revisions of the international list. The joint-cause relationship expressed in the 1933 manualremained relatively unchanged until this method ofselection was discontinued under the sixth revision ofthe international list, initiated in 1949.

The Sixth Decennial International Revision Con-ference agreed that the cause to be tabulated shouldbe the underlying cause of death. It concluded that themost useful statistic for public health purposes is theprecipitating cause, that is, the disease or injury thatinitiated the train of morbid events leading directly todeath or the circumstances of the accident or violencewhich produced the fatal injury.

The sixth revision included a revised InternationalForm of Medical Certificate of Cause of Death. Therevised format elicits information from the certifyingphysician as to the sequence of events leading todeath. It provides space for an opinion as to the director immediate cause of death, intervening causes, theunderlying cause starting the train of events leadingto death, and a list of other unrelated but contributingcauses. This method of selecting the cause of death forstatistical purposes was not adopted either in theUnited States or internationally until the sixth revi-sion of the ICD was implemented in 1949. The United


States, however, used the revised form during the1940’s prior to dropping use of the joint-cause manual.This made it possible to compare the opinions ofphysicians and coroners as to cause of death with thepreference indicated in the joint-cause manual.

This revised selection procedure, still in effect,places responsibility on the physician for reportingcauses of death in such an order that the underlyingcause of death is indicated by its position on thecertification form. It also makes it incumbent upon thenosologist (a person trained to classify diseases inaccordance with an organized list of diseases andinjuries) to distinguish between properly and improp-erly reported sequences and requires classificationrules to be applied in such cases.

Comparability studies

Each revision of the international list of causes ofdeath has produced breaks in the comparability ofmortality statistics. Over the years efforts have beenmade to evaluate the effects of the classification changesbetween revisions. Early attempts were limited inboth scope and success.

A new approach to the problem was introduced byDr. Halbert L. Dunn and William Shackley, in a studyof the effect of classification and associated coding-rulechanges on death rates, as distinguished from theeffects of other factors (Dunn and Shackley, 1944)(8).Among the other factors mentioned in the study weredecreased fatality due to particular causes as a resultof advances in medical science, increased popularityamong physicians of causes brought to the forefrontthrough widely published investigations, and the fre-quently observed excess mortality from all diseasescaused by epidemics of communicable diseases.

In this study of the effects of classification changes,all deaths reported for 1940 were first classified accord-ing to then-current methods. For comparison, the samecertificates were again classified using methods ineffect immediately preceding the introduction of the1938 revision of the international list.

The study presents percentages that show theextent to which comparability had been lost by eachinternational list cause after the adoption of the 1938revision. These percentages are presented as ‘‘reliableevaluations which will be found useful in correcting1940 death rates for incomparability due solely toclassification changes.’’ The authors point out that thecorrections apply strictly to 1940 mortality statistics,and although they apply in a general way to thestatistics for the decennial period from 1939 to thetime of the next list revision, nonclassification factorsmay also introduce discontinuities during that period.Consequently, the authors state ‘‘it cannot safely beassumed that the same adjustments can be madeconsecutively for each of those years.’’

Dunn and Shackley’s study provided the basis forthe recommendation of the international conferencefor the sixth revision, which convened in 1948. Theconference recommended that deaths occurring in thecountry in 1949 or in 1950 be coded and tabulatedtwice for the Detailed List of Causes of Death, onceusing the classification procedures for the fifth revi-sion and again using the sixth revision. These datawere then to be published in such a way as to indicatechanges resulting from the new revision. Effectivewith the sixth revision, the United States has sinceused this method to measure discontinuities in mortal-ity data resulting from revisions of the ICD.

NCHS has published reports providing estimatesof the discontinuities between the fifth and sixth revi-sions (9), sixth and seventh revisions (10), seventh andeighth revisions (11), and eighth and ninth revisions(12) of the International Classification of Diseases.

Ranking causes of death

Reference to the ‘‘leading’’ causes of death is apopular way of discussing cause-of-death statistics.The rank order of any cause depends upon the list ofcauses being ranked and the method of ranking. Forcomparing rankings among different geographic areasby characteristics of the population such as age, race,and sex, and from one time period to another, estab-lished, consistently applied procedures are essential. Aprocedure for ranking causes of death for official mor-tality statistics was developed by a working group onmortality statistics and recommended by the PublicHealth Conference on Records and Statistics at its1951 meeting. The procedure stipulated that the ‘‘Listof 64 Selected Causes of Death’’ (an expansion of theAbbreviated List of 50 Causes of Death, Sixth Revi-sion, designed for use in the National Office of VitalStatistics) be used and the following rules applied:

+ Omit the group titles ‘‘Major cardiovascular-renaldiseases’’ and ‘‘Diseases of the cardiovascular sys-tem’’ and the single titles ‘‘Symptoms, senility andill-defined conditions’’ and ‘‘All other infective andparasitic diseases’’

+ Rank the remaining group titles and single titles,omitting any title appearing under a group titleincluded in the ranking

+ Apply this procedure to deaths by age, race, andsex, with the exception of deaths under 1 year ofage

+ In published tables of rank order, indicate the listof causes of death that have been ranked, and theprocedure used

Effective with 1969 data, category titles beginningwith ‘‘other’’ or ‘‘all other’’ were dropped from theranking.


This ranking procedure has been used continu-ously beginning with 1950 data. The list of causesproviding the basis for ranking has changed slightlyover the years and currently has 72 causes. Effectivewith data year 1987, the category human immunode-ficiency virus infection (HIV infection) was added tothe list of rankable causes. Alzheimer’s disease wasadded to the list beginning with data year 1994.

A separate cause-of-death ranking for infants wasformalized in 1979 with the introduction of the ninthrevision of the ICD. The ranking was based on the Listof 61 Selected Causes of Infant Death. The group titles‘‘Certain conditions originating in the perinatal period’’and ‘‘Symptoms, signs, and ill-defined conditions’’ areomitted from the ranking. Effective with data year1987, HIV infection was added to the list of rankablecauses of infant deaths also.

Automated mortality data system

In the late 1960’s, NCHS gave high priority to thedevelopment of automated entry, classification, andretrieval of information reported on death certificates.The system is being developed and implemented bycomponents and is continuously updated to meet newrequirements and incorporate advanced technology.

The first component of the mortality data systemwas the Automated Classification of Medical Entities(ACME). Beginning with 1968 data, NCHS beganusing ACME for selecting the underlying cause ofdeath, replacing manual selection by a nosologist. Thiscomputer system was designed to apply the same rulesas those applied by a trained nosologist for selectingthe underlying cause of death from the reported medi-cal conditions on the death certificate.

ACME requires the manual coding of each entity(disease, accident, or injury) reported in the medicalcertification section of the death certificate. From thosecodes, which retain the location and order as reportedby the certifier, the computer program automaticallyassigns the underlying cause of death for each recordaccording to the selection and modification rules of theapplicable revision of the ICD published by the WorldHealth Organization. The decision tables by which theselection is made, developed by experienced nosolo-gists in consultation with medical and classificationspecialists, introduced a new consistency into the selec-tion process. The tables are updated periodically toreflect new information on the relationships amongmedical conditions and to convert from one revision toanother of the ICD.

The second component of the mortality data sys-tem to be implemented was TRANSAX, which wasdeveloped (1978–80) to facilitate the tabulation anduse of multiple cause-of-death data. TRANSAX trans-lates the axis of classification from an entity to a

record basis by accommodating linkages of entitiesprovided for by the ICD. For example, diabetes andacidosis both stated on the record become diabeteswith acidosis. A data retrieval system (RETRIEVE)was developed in conjunction with TRANSAX to searchthe files for a particular disease or injury, making itpossible to count the number of deaths for which thatcondition was reported alone or with other conditionsand, if the latter, to identify the conditions and countthe number of deaths for which such combinationsoccurred.

Another development for the mortality data sys-tem began in 1985 on the Mortality Medical Indexing,Classification, and Retrieval (MICAR) system. MICARwas designed to replace the manual coding required byACME. With MICAR, data-entry operators enter fulltext, abbreviations, or reference numbers for cause-of-death terms on personal computer data-entry screensthat are similar to the format of a death certificate.After certificates are keyed, MICAR matches eachentry (text, abbreviation, or reference number) to theMICAR dictionary and assigns the entity referencenumber that is the unique identifier in the dictionaryfor that cause. Any record with an unmatched term isrejected for manual review.

MICAR makes code assignments to each entitybased on the presence or absence of cause-of-deathterms and their positional relationship to one another,just as was formerly done manually in preparation forselection of the underlying cause of death by ACME.By automating coding rules, MICAR ensures accurateand consistent application of complex coding rules. Italso reduces personnel and training requirements. Itprovides access to every term reported on the deathcertificate, even those included with other diseases inone ICD category. This detail was not previouslyavailable.

A further improvement now underway is SuperMICAR, designed to capture the entire medical cer-tification portion of the death certificate, acceptingentry of all terms in the order in which they appear.This eliminates reordering the terms into a stan-dard order at time of entry, leaving that to thecomputer. Super MICAR not only facilitates theediting, querying, and coding functions, but alsoprovides the potential for printing certified deathcertificates from the computer.

The various components of the Automated Mortal-ity Data System have been and continue to be imple-mented on a State-by-State basis as automationcapabilities and resources permit.

Electronic registration

With the emergence of automated data-processingcapabilities, attention has been directed to automating


registration of vital events. In an electronic environ-ment, records should be created, edited, coded, que-ried, and corrected at the source in an electronicformat. To date, most progress has been made inautomating birth registration. More than one-half ofthe States have or are in the process of developing andimplementing that capability. For data year 1995,almost 70 percent of all births were registered electroni-cally. Pilot studies are being conducted toward devel-opment of an electronic death certificate, but arecomplicated because demographic information on thedecedent and cause of death are obtained from differ-ent sources.

Electronic preparation and transmittal of birthcertificates not only eliminates duplicate (in somecases triplicate) data entry but also produces moreaccurate information with greatly reduced need forquery. This permits flexibility in shifting resources touse in conducting audits of the quality of data on thecertificates. It also greatly improves timeliness of data.Once electronic entry of the cause-of-death certifica-tion is achieved, electronic preparation and transmit-tal of death certificates will produce advantages similarto those for birth certificates.

In September of 1994, a working group was formedby NCHS and NAPHSIS to begin discussions ofre-engineering the death-registration system usingstate-of-the-art technology. The group also includedrepresentatives from other components of CDC andother Federal agencies, and users and providers of thedata, such as the American Health Information Man-agement Association, American Hospital Association,American Medical Association, International Associa-tion of Coroners and Medical Examiners, NationalAssociation of Medical Examiners, and the NationalFuneral Directors Association. The work group wascharged with examining the current registration pro-cess and practices to determine the best means formeeting the various uses of the vital statistics data inthe future.

The guiding principles employed by the workgroup are that the system that is developed must be(a) capable of adapting to changing technology, infor-mation needs, and legal mandates; (b) capable ofmeeting customer needs for prompt registration andinformation; (c) capable of providing quality informa-tion appropriate for its customers while minimizingthe reporting burden on suppliers; (d) acceptable tothe individuals, organizations, and institutions whoparticipate in the system; and (e) capable of incorpo-rating methods to measure the reliability and valid-ity of the data collected. The working group willdevelop recommendations for the design of an elec-tronic system built around these guiding principles.It is anticipated that by the year 2000, electronicdeath certificate systems will be in place in themajority of the States.

Multiple causes-of-death statistics

The traditional selection of a single cause of deathfor national statistical tabulations resulted in the lossof valuable medical information. In recognition of this,national coding of more than one cause was under-taken in a few scattered years, the most ambitiousbeing in 1955 when up to five additional causes werecoded. In the 1970’s, utilizing this source of medicaldata became a major objective of the vital statisticsprogram. The Automated Mortality Data System wasdeveloped to provide not only underlying cause-of-death statistics, but through its TRANSAX andRETRIEVE components, to include the capability totabulate multiple causes. It is now possible to countthe number of deaths for which any given disease orinjury was reported as a cause, alone or in combina-tion with other causes. All of the various combinationscan also be identified and counted. Data for 1978 werethe first national data published from this system. Itappeared in MVSR, Volume 32, Number 10, Supple-ment 2, February 17, 1984.

Race and ethnicity data

Obtaining valid vital statistics for populations ofspecific race or national origin is complicated by thevast number of possibilities and the uncertaintiesinherent in providing and obtaining classifiableresponses. Only the use of broad categories has provenfeasible, but in spite of this, pressure for expandingdetail increases. This coincides with increasing inter-est in information concerning specific ethnic or racialgroups.

The birth certificate does not provide for reportingof race of the newborn. Prior to 1989, for statisticalpurposes, classification of the child’s race or nationalorigin was based on the race or national origin of theparents. When both parents were not of the same raceor national origin, rules had been established forcoding various combinations. If only one parent waswhite, the child was assigned the race of the otherparent. If neither parent was white, the child wasassigned the race of the father, with one exception: Ifeither parent was Hawaiian or part-Hawaiian, thechild’s race was assigned to Hawaiian.

Rules were also established for assigning the child’srace when race of the parents was not stated. If racewas missing for one parent, the child was assigned therace of the other parent. When race was missing forboth parents, the race of the child was considered notstated.Assignment of race for these records has changedover the years. These changes in classification ruleshave produced differences in statistics for racial cat-egories, relatively small for some categories, greaterfor others. The size of the differences for racial andnational-origin groups is discussed in the technical


appendices from the volumes of Vital Statistics of theUnited States for the respective years.

Beginning with 1989 data, natality tabulationswere modified to show race of the mother, rather thanrace of the child. Criteria for reporting race of theparents did not change. The change in tabulation wasmade because the 1989 revision of the standard certifi-cate of live birth included many new items related tothe mother (that is, weight gain during pregnancy,alcohol and tobacco use, medical-risk factors, obstetricprocedures, and method of delivery). It was deter-mined to be more appropriate to use the race of themother in tabulating these items. Many of the otheritems on the certificate also related to the mother,including age, education, month of pregnancy thatprenatal care began, number of prenatal visits, mari-tal status, and date of last live birth.

Growth of the Hispanic population in the UnitedStates stimulated interest in obtaining vital statisticsinformation pertaining to that group. During the reviewprocess for the 1978 revision of the U.S. standardcertificates and reports, organizations interested inHispanic data requested that an item be added forcollecting statistics on the Hispanic-origin population.The Technical Consultant Panel (TCP), appointed bythe Public Health Conference on Records and Statis-tics Standing Committee, was given the task of review-ing the 1968 revisions of the standard certificates anddeveloping drafts of new standard certificates andreports.

The TCP recommended that the five southwesternStates with substantial Hispanic minorities (Califor-nia, Colorado, NewMexico, Arizona, and Texas) developbirth and death statistics for the population of His-panic origin in their States. It further recommendedthat the list of Hispanic surnames used in conjunctionwith the 1980 census be used for this purpose. NCHSand the parent group of the panel agreed with therecommendation.

However, in June of 1976, a joint resolution ofCongress (Public Law 94–311) required Federal agen-cies to begin collecting and publishing data on Ameri-cans of Spanish origin or decent. Therefore, althoughan item on ethnic origin was not added to the certifi-cates in the 1978 revision, NCHS recommended thatthe five southwestern States and other States havingsignificant Hispanic-origin populations, develop asuitable Hispanic-origin identifier for use on the birthand death certificates. Work began with those Statestoward that objective. During the 1980’s the number ofStates including a Hispanic identifier on their birthand death certificates steadily increased, and NCHSwas able to publish both natality and mortality datafor this population.

The 1989 revisions of the live birth, death, fetaldeath, and induced termination of pregnancy formsinclude a Hispanic-origin question. In addition, NCHS

developed a general ancestry question as an option forthose States without enough Hispanic population tojustify the specific question or for those that may havea need for data on other segments of their population.

In the 1989 revision of the standard certificatesand reports, an item requesting yes or no for Hispanicorigin and ‘‘if yes, specify’’ was added for mother andfather on the live birth and fetal death forms, fordecedent on the death certificate, and for patient onthe induced termination of pregnancy form. The His-panic identifier was not recommended for the mar-riage and divorce certificates.

Mortality statistics for the Hispanic-origin popula-tion were published for the first time for 1984 andincluded data for 22 States and the District of Colum-bia. Natality statistics for the Hispanic-origin popula-tion were first published with the 1978 data andincluded 17 States. The 1994 data for the Hispanic-origin population included mortality statistics for 49States and the District of Columbia and natality sta-tistics for 50 States and the District of Columbia.

Fetal death and induced termination ofpregnancy data

NCHS adopted the definition of fetal death recom-mended in 1950 by the World Health Organization.Fetal death was defined as ‘‘death prior to the com-plete expulsion or extraction from its mother of aproduct of conception, irrespective of the duration ofpregnancy.’’ The World Health Organization recom-mended that for statistical purposes, fetal deaths beclassified as early (less than 20 completed weeks ofgestation), intermediate (20 completed weeks of gesta-tion but less than 28), late (28 completed weeks ofgestation and over), and gestation period not classifi-able as early, intermediate, or late.

Until 1939, the procedure recommended nation-ally for registering a fetal death required the filing ofboth a live-birth certificate and a death certificate. In1939 the filing of a newly implemented standard cer-tificate of stillbirth (fetal death) replaced the previousprocedure. This form, undergoing several revisions,later became the U.S. Standard Certificate of FetalDeath and, in 1978, the U.S. Standard Report of FetalDeath.

In 1969 CDC established an abortion surveillancesystem to obtain and publish data on induced abor-tions for each State. They have published data continu-ously since that time and are the only source ofnational data on induced abortions available from theFederal Government.

The Supreme Court decision of 1973 that madeinduced abortion legal prompted more intensive effortsto obtain national abortion statistics. In the early1970’s, NCHS began developing a national abortion


reporting system similar to the reporting system usedfor other vital events. The intent was for the datasystem developed by NCHS to eventually replace theabortion surveillance system in CDC. The abortion-reporting area funded by NCHS gradually expanded,as additional registration areas met reporting criteriaand as Federal funding became available. However,less than one-half the States established reportingsystems that met the NCHS criteria and funding forthis program was very limited. As a consequence,NCHS was able to obtain data from only 15 States.Because the prospects for expanding the system anyfurther were unlikely, funding for the system wasdiscontinued by NCHS after data year 1993.

Linked birth/infant death data

Infant mortality rates are one of the most widelyused measures to gauge the overall health of a commu-nity. Researchers and public health officials are con-stantly looking for data to help them better understandthe causes of infant deaths and to plan strategies andinterventions to reduce the number of deaths. Awealthof additional data can be obtained by linking the birthcertificates of infants with their death certificates.

The States have a long history of matching birthand infant death certificates for both statistical andregistration purposes. NCHS undertook its first majoreffort to create a national file of linked birth and infantdeath records for the birth cohort of 1960. The file wasconstructed by collecting actual copies of linked birthand death certificates from each of the 50 States andthe District of Columbia. Of the nearly 110,000 infantdeaths to the 1960 birth cohort, certificates for 97.4 per-cent were matched to the corresponding birthcertificates.

The next national linked data set was created forthe birth cohort of 1980 by the Division of Reproduc-tive Health, Center for Chronic Disease Preventionand Health Promotion, Centers for Disease Control, ina project called National Infant Mortality Surveillance(NIMS). An important side benefit of the NIMS projectwas a conference held in May 1986 in Atlanta, Geor-gia. This conference brought together representativesfrom State maternal and child health programs andState vital statistics offices to exchange information ondata needed to monitor the effectiveness and efficiencyof maternal and child health programs.

In 1985 NCHS initiated a two-stage evaluationproject to determine the feasibility of creating linkedbirth and infant death files on a routine, annual basisas part of the Vital Statistics Cooperative Program(VSCP). In stage one, a linked file was produced forthe 1982 birth cohort of infant deaths that occurred ina nine-State area. A match rate of 96.7 percent wasachieved in this pilot, which demonstrated the feasibil-ity of creating the linked file on a routine basis.

In stage two of the evaluation project, State andnational linked files for each of the birth cohorts of1983–86 were created and evaluated with data fromall States included. Because of the success of theevaluation project, the provision of the linked birth/infant death file to NCHS was added to State VSCPcontracts beginning with the 1987 birth cohort.

Beginning with data year 1995, a significant changewas made in the way States provided the linked datato NCHS. Rather than providing the linked informa-tion as a birth cohort, they provided it on a periodbasis, based on the year of death of the infant, not theyear of birth. This change will have a major impact onthe timeliness of the release of data from the linkedfile. It will also allow for the release of the linked dataset both as a period and birth cohort file, making iteven more useful. The development of the linked filehas proven to be an invaluable tool in the ongoingstruggle to reduce the infant mortality rate.

Training

The Applied Statistics Training Institute (ASTI)was established in 1967 as part of the Office of StateServices in NCHS. The short-term training courseswere designed to meet the needs of State and localvital and health statistics personnel for concentratedtraining in practical aspects of health statistics. Aworkshop on cause-of-death coding was included in thetraining curriculum. In the first year, more than 100experienced coders from 35 States were trained in theeighth revision of the ICD.

NCHS provided leadership in the training of pub-lic health statisticians through the ASTI programthrough 1982, when the program was discontinuedbecause of budget restraints.

The Division of Vital Statistics assumed the respon-sibility to continue training State vital statistics per-sonnel in vital registration methods and statistics.Because the division had worked closely with Stateand local vital statistics offices in improving timeli-ness, completeness, and quality of the data, it waslogical for DVS to teach the courses being abolished bythe dissolution of ASTI. Beginning in 1983, DVS offeredtwo classes: ‘‘Vital Statistics Records and Their Admin-istration,’’ which focuses on matters related to the vitalregistration system, and ‘‘Vital Statistics: Measure-ment and Production,’’ which is a basic vital statisticscourse with emphasis on measurement and data qual-ity. DVS has continued to offer these courses to Stateand local personnel annually. Equally important wasthe continuation of nosology classes that focused onmedical coding. The Division of Data Processingassumed the responsibility for these courses and hasheld them annually since 1983.

A comprehensive disease prevention and healthpromotion initiative, Healthy People 2000, produced


an increase in demand for public health statistics andan increased need for training. As a result, in 1991steps were taken to reestablish the ASTI program. Aseries of short-term courses was developed for workingpublic health professionals to guide in setting andevaluating health objectives for the year 2000. Now anongoing program, ASTI offers courses that focus oncurrent public health concerns. The goals set forth are:to train health professionals in the use of statisticaltools; to apply statistical methods in assessing publichealth problems; to provide early training relevant tostatistical requirements of current health legislationand directives; to provide training in effective decisionmaking employing statistical models; and to improvetechniques of data collection, analysis, and utilization.

Special projects

Special projects conducted by NCHS have madeimportant contributions in the realm of vital andhealth statistics. These projects include tests of regis-tration completeness; revisions of the U.S. standardcertificates and reports; studies of the effect of thedecennial revisions of the ICD on the comparability ofcause-of-death statistics; and analyses of natality, mor-tality, and other vital statistics for presentation tovarious medical, health, and other associations.

Two unique projects were undertaken by NCHSduring the 1960’s that contributed substantially to thebody of published vital and health statistics and analy-ses. One was a volume containing vital statistics ratesfor a 20-year period (1940–60) on mortality, natality,marriage, divorce, and life expectancy. The otherinvolved technical coordinating services and data pro-duction for a monograph series focusing on the majorhealth problems of the Nation.

Vital statistics rates in the United States:1940–60

The volume Vital Statistics Rates in the UnitedStates, 1940–60 (13), coauthored by Robert D. Grove,Ph.D., and Alice M. Hetzel, brings forward to 1960 thebasic mortality and natality data included in the pre-viously published volume, authored by Forrest E.Linder, Ph.D., and Robert D. Grove, Ph.D., coveringthe period 1900–40 (14). It also provides statistics onlife expectancy, marriages, and divorces, which werenot covered in the earlier volume. This work showssome of the basic series back to the earliest year forwhich data are available. Population data from theBureau of the Census used in the computation of ratesare also included. The text provides a description ofthe vital statistics system, definitions and uses of vitalstatistics rates and ratios, qualifications of the data,and charts summarizing trends for selective vital sta-

tistics series. In 1996 a new volume was being com-piled titled Vital Statistics Rates in the United States:1969–93.

Vital and health statistics monographs,1959–61

In the early 1960’s, the American Public HealthAssociation sponsored a monograph series to presentan indepth study of vital and health statistics. Thestudy was proposed in October 1958 by the statisticssection of the APHA. As chairman of the Committee onVital and Health Statistics Monographs, MortimerSpiegelman, associate statistician of the MetropolitanLife Insurance Company, spearheaded the proposaland became principal investigator for the project. Thecommittee selected the topics to be covered by theseries and suggested authors for the monographs.Conferences were held with authors to establish gen-eral guidelines for the preparation of the manuscripts.

Support for this undertaking in its preliminarystages was received from the Rockefeller Foundation,the Milbank Memorial Fund, and the Health Informa-tion Foundation. Major support for the required tabu-lations, for writing and editorial work, and for therelated research of the monograph authors was providedby the Public Health Service (Research Grant HS 00572,formerly CH 00075, and originally GM 08262).

This study was initiated in response to an increas-ing awareness both inside and outside of the Govern-ment of the need for information defining the majorhealth problems of the Nation. The study was designedto present critical analyses not only of current vitalstatistics and health data but also of trends as indi-cated by data collected over the years. The study wastimed to utilize the extensive population data from the1960 census for computation of rates by various char-acteristics of the population. The monographs wereexpected to provide information useful for programand research planning and for educational and generalinformation purposes. First conceptualized as a mono-graph series based on 3 years of death statistics cen-tered around the 1960 census, the project was soonbroadened to include pertinent findings from specialsurveys and studies of social and economic factors notonly in mortality but in morbidity and fertility as well.

Under the leadership of Robert D. Grove, Ph.D.,National Office of Vital Statistics, NCHS, and a mem-ber of the Committee on Vital and Health StatisticsMonographs, NCHS produced special detailed tabula-tions and computations for the 1959–61 period andperformed technical coordinating services for theproject. NCHS provided data collected through thevital registration system, obtained population datafrom the Bureau of the Census for the rate computa-tions, and provided guidance to keep the results con-


sistent with official national figures. Other majorsources of statistical data included the National HealthSurvey and the University of Chicago study of socialand economic differentials in mortality based on amatched file of 1960 census records and deathcertificates.

To achieve some comparability among mono-graphs, a standard set of mortality tabulations wasproduced for each, using the same classifications forselected characteristics. In general, monograph authorswere able to obtain additional tabulations and ratecomputations of their choosing from available datawithout need to conform to a uniform pattern.

The Vital and Health Statistics Monographs, 1959–61, were published by Harvard University Press, Cam-bridge, Massachusetts. Titles and authors are as follows:

b Infant, Perinatal, Maternal, and ChildhoodMortality in the United States, by Sam Shapiro,Edward R. Schlesenger, and Robert E.L. Nesbitt, Jr.b Trends and Variations in Fertility in the UnitedStates, by Clyde V. Kiser, Wilson H. Grabill, andArthur A. Campbellb The Epidemiology of Oral Health, by Walter J.Pelton, John B. Dunbar, Russell S. McMillan, PalmiMoller, and Albert E. Wolffb Cardiovascular Diseases in the United States, byIwao Moriyama, Dean E. Krueger, and JeremiahStamlerb Digestive Diseases, by Albert Mendeloff and JamesP. Dunnb The Frequency of Rheumatic Diseases, by SidneyCobb, M.D.b Tuberculosis, by Anthony M. Lowell, Lydia B.Edwards, and Carroll E. PalmerbMarriage and Divorce: A Social and EconomicStudy, by Hugh Carter and Paul C. Glickb Infectious Diseases, by Carl Calvin Dauer, Robert F.Korns, and Leonard M. SchumanbMortality and Morbidity in the United States, byCarl L. Erhardt and Joyce E. Berlinb Accidents and Homicide, by Albert P. Iskrant andPaul V. Jolietb Differential Mortality in the United States: A Studyin Socioeconomic Epidemiology, by Evelyn M.Kitagawa and Philip M. Hauserb Epidemiology of Neurologic and Sense OrganDisorders, by Leonard T. Kurland, John F. Kurtzke,and Irving D. Goldbergb Cancer in the United States, by Abraham M.Lilienfeld, Morton L. Levin, and Irving I. KesslerbMental Disorders/Suicide, by Morton Kramer, EarlS. Pollock, Richard W. Redick, and Ben Z. Lockeb Syphilis and Other Venereal Diseases, by William J.Brown, James F. Donohue, Norman W. Axnick,Joseph H. Blount, Neal W. Ewen, and Oscar G.Jones

Cooperative developments

Vital statistics component of theCooperative Health Statistics System

The Cooperative Health Statistics System (CHSS)was formally established by the Health ServicesResearch, Health Statistics, and Health Care Technol-ogy Act of 1978 (Public Law 95–623). The statedpurpose was the production of ‘‘comparable and uni-form health information and statistics.’’ Vital statis-tics, included as one of seven components, provided thenucleus of the system. It received high priority forinclusion in the system because of its importance inproviding population-based information essential inidentifying health and social problems. It also had along history of successfully obtaining data through aFederal-State cooperative arrangement.

Considerable departmental and legislative activitypreceded formalization of the CHSS. Soon after NCHSwas established to coordinate activities in the field ofnational health statistics, there was an increasedawareness of the potential for broadening Federal-State cooperative activities to include a variety ofhealth statistics.

During the late 1960’s and early 1970’s, referencesto a cooperative health statistics system occurred fre-quently in departmental memoranda, in testimoniesat hearings before House and Senate Committees, andin various pieces of legislation. The first steps towardthe development of a cooperative health informationand statistics system were authorized by the HealthServices Improvement Act of 1970. It authorized theSecretary of the Department of Health, Education,and Welfare ‘‘to undertake research, development, dem-onstration, and evaluation relating to the design andimplementation of a cooperative system for producingcomparable and uniform health information and sta-tistics at the Federal, State, and local levels.’’ Fundsfor this effort were appropriated to the National Cen-ter for Health Services Research and Development.Under this authorization, collection of vital statisticsdata through this arrangement began in 1973. Theongoing national vital statistics program, already oper-ating through the cooperative efforts of Federal, Stateand local governments, was the first component fundedunder this act.

The cooperative system was envisioned as a sys-tem that would use standard definitions, standardmeasurements for quality, and standard methods forcollecting, processing, and analyzing health statistics.Data originating at the local level would be producedin content and form for use not only at the local levelbut at the State and Federal levels as well. Throughelimination of duplicative efforts, more efficient use ofresources and equitable cost-sharing, data of greater


detail and better quality would be available to alllevels of government.

The vital statistics program already embodied thebasic principles of the proposed CHSS. The recordswere being produced by local officials, sent to the Stateoffices of vital statistics for permanent maintenance incentral State files, and for use in compiling and pub-lishing statistics for State and local areas. The Stateoffices forwarded copies of the records to NCHS, wheredata were edited, coded, tabulated, and published forthe Nation.

These procedures began to change in 1971, asNCHS began to accept magnetic tapes of State-codeddata, coded according to NCHS specifications. NCHSwas providing leadership not only in promoting unifor-mity in form and content of vital records and registra-tion laws but also in developing new methods for datacollection, processing, and dissemination. The birthand death statistics constituted the only series ofannual health statistics that covered all events fromall jurisdictions in a uniform manner according tospecified standards. Although the framework existed,however, there was a recognized compelling need toaccelerate improvement of the quality and uniformityof data, to modernize collection and processing meth-ods, to eliminate State-Federal duplication, and toestablish an equitable cost-sharing mechanism.

The vital statistics component of the CHSS involvedsix data sets or subcomponents: births; demographicdata for deaths; medical (cause-of-death) data fordeaths; marriages; divorces; and abortions. By 1973six States had already entered into contracts with theDivision of Vital Statistics of NCHS to provide com-puter tapes of birth and demographic death data underthe Vital Statistics Cooperative Program (VSCP).Throughout the early developmental period, availablefunds were insufficient to bring into the VSCP allStates technically ready and interested in a contract.Some States provided tapes to NCHS prior to availabil-ity of funding. Contracts were negotiated with addi-tional States subject not only to technical readinessbut to availability of funds. Funding birth and demo-graphic death data in non-VSCP States was givenpriority over extending subcomponent coverage inStates already in the program. Several States, how-ever, were technically able to and did include cause-of-death data in their first contract.

Beginning in 1971 with the State of Florida(unfunded), the number of States submitting one ormore subcomponents of data to NCHS on computertape steadily expanded as funding became available.By the 1985 data year, all States, the District ofColumbia, New York City, Puerto Rico, and the VirginIslands were submitting birth data and demographicdeath data on tape. In 1995, 42 States and the Districtof Columbia were submitting medical death data ontape.

Prior to implementation of the VSCP, the FederalGovernment reimbursed the States for use of theirvital records for national statistics at the rate of 4cents per record. The first VSCP contracts were nego-tiated individually with the participating States. Itsoon became evident that equitable funding among theStates required development of a rationale for costsharing that could be applied to all States.

In January 1981, Dorothy P. Rice, then director ofNCHS, established a working group on the completionof the VSCP. The working group was made up ofNCHS staff members appointed by the NCHS directorand State representatives appointed by the presidentof the Association for Vital Records and Health Statis-tics (AVRHS). The group served as a forum in the jointeffort of NCHS and AVRHS to define the State/localactivities involved in producing vital statistics for useat all levels of government, the cost of those activities,and a rationale for determining the Federal share ofthat cost. Development of standardized funding crite-ria to ensure equitable funding among States, andsimplification of the contracting process for the VSCPcontracts were also major concerns.

The working group constructed a model for stan-dardizing funding among States in terms of in-scopeactivities and levels of effort. The model provided for acost formula limited to the accepted level of effortnecessary to carry out the in-scope functions of thevital statistics contracts. The working group recom-mended that implementation of the formula be phasedin over a 3-year period beginning with fiscal year (FY)1983, and that after sufficient experience, the formulabe reevaluated and revised if necessary.

In May 1986, Dr. Manning Feinleib, then directorof NCHS, established a working group to review theVSCP cost formula and to develop recommendationsconcerning revision. As with the previous workinggroup, membership was made up of representativesfrom NCHS and AVRHS.

The working group recommended updating thecost formula, eliminating reference to the ‘‘Federalshare’’ in favor of a funding level derived from a baselevel with annual cost-of-living adjustments (COLA’s).For FY 1989, funding was to be established at the FY1988 level plus a 4.9-percent COLA, with additions forthe cost of collecting and processing new items of data.In succeeding years funding would be established byadding a COLA to the previous year’s level. Additionalfunds would be provided for implementation of newcomponents. Reduction in the scope of a programwould be required to offset any reductions in funding.Full funding to a State would be dependent on thereporting of all minimum basic data-set items. The feefor procurement of photocopies or microfilm copies ofrecords would be increased from 4 cents to 10 cents perimage.


In the fall of 1992, Dr. Feinleib established thesecond working group to review the VSCP cost for-mula. This working group was charged with reviewingthe experience of the last 5 years to evaluate theadequacy of the current formula to (a) adequately andfairly distribute funds among States and (b) assure itsrelevancy to the current and future operations of theVSCP. Membership again was made up of representa-tives from NCHS and AVRHS. The 1992 workinggroup recommended that no changes be made in theelements used in the formula to determine the distri-bution of funds. They also recommended that the 1993contracts be extended through 1994 and new contractsbe written for 1995–99 data. Data on staffing andsalaries were collected in 1995 for use throughout the1995–99 contract period, with annual adjustments forcost of living. In previous contracts, staffing and salaryinformation had been obtained on an annual basis.The committee also discussed the need to modify theformula to reflect automated birth and death systemsunder development in the States. However, becausenot all States were at the same point in the develop-ment of these systems, the working group recom-mended that no changes related to automation bemade in the formula at this time. NCHS and AVRHSagreed to develop appropriate cost and staffing modelsto reflect an automated vital record system prior to thenext VSCP formula revision.

The working group also discussed ways to encouragetimeliness, at both the State and national levels. Thenew cost formula recommended that States provide datato NCHS as soon as they are received and initiallyprocessed, rather than waiting until all quality control iscompleted. Updated records were to be transmitted asamendments were processed. This would allow NCHS toprocess and release the data more rapidly.

The working group agreed that in addition to anannual release, data should be published and dissemi-nated on a ‘‘flow’’ basis as they become available. TheNCHS current-flow publication plans are discussed inthis report under ‘‘Vital Statistics in the 21st Century:A Vision for the Future.’’ Thus, the 1995–99 contractset the stage for moving the vital statistics systemtoward automation, improved timeliness, and new data-release products.

State centers for health statistics

The concept of State centers for health statisticsoriginated in the 1970’s under the CHSS. They were tobe semi-autonomous organizations housed primarilyin State health agencies that would collect and ana-lyze the major health data bases and be a resource forstatistical analysis and consultation. During the late1970’s and the 1980’s, efforts were made to obtainofficial State designation for these centers, either

through legislation or executive order. In 1980, thePublic Health Service developed proposed guidelinesfor the characteristics, authority, statistical mission,and functions of the State centers. These guidelineswere published in the Federal Register (July 22, 1980).However, the guidelines were not adopted as regula-tions by the Public Health Service, although they haveserved as a model for some States to follow in settingup a comprehensive health statistics program.

All 50 States and the District of Columbia havedesignated State centers for health statistics, but withvarying results. State centers have diverse capabili-ties, ranges of authority, and placements within Stategovernment. Although in most States the center is apart of the health agency, in some the center is locatedin a human resources agency, or in one case, in thebudget and control board. In a few States, the Statecenter plays a major role in the development of infor-mation needed for assessment, policy development,and assurance. There are also a number of Statecenters whose function is limited to the tabulation andanalysis of vital statistics.

Supplemental data sourcesAnumber of special data-production activities have

been undertaken as part of the vital statistics pro-gram. They include follow-back surveys and theNational Survey of Family Growth (NSFG), conductedto augment vital records data, and the National DeathIndex (NDI) established in 1981 as a central source ofinformation to aid researchers.

Follow-back surveys

In the mid-1950’s the National Office of VitalStatistics in collaboration with other agencies beganconducting studies anchored to vital records. The stud-ies were undertaken with the cooperation of the healthdepartments of the vital registration areas. The healthdepartments approved the studies, authorized the useof vital records in the studies, and when appropriate,cleared the studies with the State medical societies.The vital record was the basic sampling unit. The totalfile of vital records for the given event during the givenperiod was the sampling frame. Supplementary infor-mation about each event was collected from sources ofinformation identified on the certificate. The samplefigures were inflated to provide unbiased estimates forthe universe from which the sample was selected.

These surveys served as pilot tests for developingsurvey methodology for collection of national morbid-ity, mortality, and medical care data and related socio-economic differentials. They include the following:

+ The National Lung Cancer Mortality Study(National Cancer Institute, 1956–57) served as a


pilot test for the National Lung Cancer Studyconducted later

+ The Illness Study of Deceased Persons in the MiddleAtlantic States (National Health Survey Program,1957–58)

+ The National Lung Cancer Mortality Study(National Cancer Institute, 1958–60)

+ The Illinois Bone Tumor Mortality Study (ArgonneNational Laboratory, 1958–60)

+ The National Study of Socioeconomic Differentialsin Mortality (University of Chicago, 1960)

+ The National Survey of Hospitalization in the LastYear of Life (National Health Survey Program,1961)

The National Mortality Surveys were conductedannually from 1961 through 1968 and in 1986 and1993. The early surveys of the 1960’s include informa-tion on hospitalization, diagnoses, operations per-formed, income, education, health insurance, chargesfor hospital care and surgery, and smoking habits ofthe deceased. Both the 1986 and 1993 surveys includeadditional information on the access to and use ofhealth care services during the last year of life, theamount paid for health care by the decedent, thesource of other health care payments made on behalfof the deceased, and the household composition, dis-ability, comorbid conditions, cognitive functioning,drinking habits, and socioeconomic status of thedeceased.

The 1986 survey also includes information on thedeceased’s usual intake of specific food groups, use ofbirth control, sterilization, and history of heart attackamong the deceased’s parents and siblings. Hospitalrecords for the deceased provide information on diag-nostic and surgical procedures performed during thelast year of life.

The 1993 survey expands upon the earlier surveysby including additional information on the deceased’suse of assistive devices, medical devices implanted orused while living at home, motor vehicle driving behav-ior, use of drugs, access to firearms at home, organdonorship, behavior and lifestyle-related activities, placeof death, and circumstances surrounding injury-related deaths. For unintentional and intentionalinjury-related deaths, additional information collectedfrom medical examiner or coroner records includesevents leading to the death, autopsy results, and toxi-cological findings.

The National Infant Mortality Surveys were con-ducted annually from 1964 through 1966. They includeinformation about other children of the mother, house-hold composition, income, employment of mother, edu-cation of mother and father, and health insurance.

The National Natality Surveys were conductedannually from 1963 through 1969 and in 1972 and1980. They include information on medical and dental

care and radiological treatment of the mother, paren-tal education, type and length of parental employ-ment, family income, pregnancy history, expectationsof having more children, household composition, num-ber and date of marriage(s), health insurance, breastfeeding, previous pregnancies, religious preference ofhusband and wife, health status of mother and infant,whether pregnancy was wanted, and whether motherhad an operation to prevent future pregnancies. The1980 survey included fetal mortality and items onalcohol consumption, electronic fetal monitoring, amnio-centesis, and ethnicity.

The National Maternal and Infant Health Surveywas a nationally representative follow-back study ofwomen who had reproductive events in 1988. Thesample was drawn from the 1988 live birth, fetaldeath, and infant death vital records from each regis-tration area. It included women who had live births,women who suffered an infant death, and women whohad a fetal loss. It provided data on the relationship ofsuch antenatal factors as prenatal care health ser-vices, smoking, and use of alcohol and drugs, to adverseoutcomes such as fetal loss, low birthweight, andinfant death. Prior to the 1988 study, many Statesexcluded out-of-wedlock births from their sample, butbecause of favorable pretest results, most Statesincluded them in the 1988 sample.

A longitudinal followup survey was conducted in1991, in which mothers from the 1988 National Mater-nal and Infant Health Survey and their children’smedical providers were recontacted to update healthhistories of mother and child and provide informationon such subjects as child injuries, child safety, childcare and development, parental employment patterns,use of Federal assistance programs, health insurance,use of pediatric services, and subsequent fertility.

National Survey of Family Growth

The National Survey of Family Growth (NSFG)was established in response to a well-recognized needfor information that could be used to develop, manage,and evaluate Federally supported programs related tofamily planning, childbearing, and maternal and infanthealth, and to aid in refining population projections. Inthe late 1960’s, NCHS took the initiative to develop aninterview survey as one of its ongoing systems in thevital statistics program. It drew upon the expertise ofparticipants in the successful series of privately con-ducted national fertility surveys—the Growth of Ameri-can Families Surveys in 1955 and 1960 and theNational Fertility Studies in 1965 and 1970.

The NSFG supplements information from the regu-lar data collection programs of NCHS and the Bureauof the Census. In addition to providing deeper explana-tory data on birth trends (contraceptions, wanting of


pregnancies, and socioeconomic data), it provides datato expand various aspects of vital statistics, includingfetal mortality (regardless of gestation), estimates oftotal annual pregnancies, and family formation andstability. It also provides data on infertility, a criticalfactor in population replacement as well as an impor-tant area of reproductive health.

The need for such data was stated in the ‘‘Report ofthe Secretary of Health, Education, and Welfare Sub-mitting Five-Year Plan for Family Planning Servicesand Population Research Programs,’’ October 12, 1971,prepared for the Special Subcommittee on HumanResources of the Senate Committee on Labor andPublic Welfare. In that document the ongoing efforts ofNCHS were recognized, and plans for developing aNational Survey of Family Growth by NCHS were setforth.

The Commission on Population Growth and theAmerican Future, in its March 1977 report, gave astrong supporting recommendation for ‘‘. . . programsupport and continued adequate financial support forthe Family Growth Survey as almost the first condi-tion for evaluating the effectiveness of national popu-lation policies and programs.’’

The NSFG is now an integral part of the NCHSdata-collection systems. Differing from the center’sother population-based surveys, it targets a particularaspect of the health experience of a particular segmentof the total population, that is, the reproductive histo-ries of women of childbearing ages. It yields datainterrelated with other research studies of health andhealth services. As a result, it has been and continuesto be a collaborative undertaking between NCHS andother Federal agencies.

Data for the NSFG are collected in personal inter-views using nationwide cross-sectional probabilitysamples of women in the childbearing ages. In cycles Iand II of the NSFG, conducted in 1973 and 1976, thesample included women 15–44 years of age who hadever been married or, if they had never been married,had children of their own living with them. Cycle III,conducted in 1982, was expanded to include all women15–44 years of age, bringing important new informa-tion into the survey. Cycle IV, conducted in 1988,linked the NSFG to the National Health InterviewSurvey (NHIS), a continuing survey conducted everyweek of every year. The NSFG was the first surveysuccessfully linked to the NHIS in the center’s newlydeveloped integrated survey design.

The beginning and early development of the NSFGin the vital statistics system are documented in reportsof the U.S. National Committee on Vital and HealthStatistics published by NCHS in Vital and HealthStatistics, Series 4. The survey and sampling designsof the NSFG cycles appear in Vital and Health Statis-tics Series 2, and statistics derived from the surveysare published in Series 23.

National Death Index

Over the years death records have been a fruitfulsource of information for researchers in the field ofmedicine. Increasing awareness of the many and var-ied influences on the length and quality of life hasaccelerated their use. Death records are utilized instudies to identify and assess environmental healthhazards, the effects of specific therapies, the influenceof various health programs, and risk factors such asthose inherent in some chemicals, drugs, and con-sumer products. Without a national source for informa-tion on fact of death and location of the death record,obtaining access to death records for studies can be acumbersome process. It can require searches of all ofthe individual State vital statistics offices for eachsought-after record, unless the researcher knows theregistration area in which the death occurred. A singlesource for determining whether or not an individualhas died and, if so, the location of the death recordgreatly facilitates such research in terms of time,money, and effort.

This need for a central source of mortality infor-mation for use in medical and health research led toimplementation of a national death index in 1981.Leading up to this, in 1964 and again in the early1970’s, a study group was established under theauspices of the Public Health Conference on Recordsand Statistics to explore the feasibility and means ofestablishing such a source. Both study groups rec-ommended a national system for locating deathcertificates that would enable medical and healthinvestigators to ascertain at one central source thefact of and/or place of death for individuals in theirstudies.

Delay in implementing the recommendations ofthe study groups was largely the result of concern thatonce established, there would be pressure to use thesystem for other than its intended statistical purposesin medical and health research. Until the legality ofthe restrictions imposed by the participating Statescould be assured, NCHS was reluctant to undertakeresponsibility for establishing a national death clear-ance system. Interest of research groups increased,however, and early in 1976 more intensive discussionsbegan between NCHS and the AAVRPHS executivecommittee.

In August of 1976, the Office of the GeneralCounsel of the Department of Health, Education,and Welfare rendered the opinion that NCHS couldlegally limit access to information from a nationaldeath index on the basis of its confidentiality legis-lation in Section 308 (d) of the Public Health ServiceAct, 42 U.S.C. 242 m. In February 1977, in light ofthat opinion and after discussions with the execu-tive committee of AAVRPHS, the director of NCHSestablished a working group to develop plans and


procedures for the implementation of a nationaldeath index. On August 31, 1978, the working groupsubmitted its final report to the director. As theworking group recommended, the index was imple-mented beginning with 1979 deaths. The first year46 registration areas participated. A computerizeduniform standard data set has since been collectedannually from all registration areas. The system,which may be used only for statistical purposes inhealth and medical research, became available toresearchers in January 1981.

All applications for use of the NDI are reviewedby drawing on the expertise of individuals fromState vital statistics offices, NCHS staff, and usergroups such as the National Institutes of Health, theNational Institute for Occupational Safety andHealth, medical schools, and private industry. Whenapproved, applicants are instructed to submit theirrecords of study subjects on magnetic tape, floppydisks, or coding sheets. Users of the NDI are requiredto provide certain minimum information to accessthe index (that is, first and last name and either aSocial Security number or month and year of birth).The provision of additional data items is useful inassessing the quality of the resulting NDI recordmatches: middle initial, father’s surname, day ofbirth, sex, race, marital status, State of residence,and State of birth.

Once the NDI search is completed, the user isprovided with the State and date of death for eachpossible NDI record match and the correspondingState death certificate number as it appears in theindex. The user must then contact the appropriateStates and purchase copies of the death certificates toobtain additional information such as cause of death.Although States submit their death records to theFederal office for statistical compilation, analysis, andpublication, they reserve the right to respond to allinquiries concerning individuals and to require addi-tional information and confidentiality assurances fromthe NDI users.

To enhance the services provided to researchers,the NDI program initiated a pilot study in 1995 todetermine the feasibility of also providing the codedcauses of death to NDI users. NCHS and the NationalAssociation for Public Health Statistics and Informa-tion Systems (NAPHSIS) are currently evaluating thepilot results. If the pilot leads to a general implemen-tation, NDI users will have the option of obtainingcoded causes of death for selected potential matches aspart of their NDI output.

As of September 30, 1995, the NDI file containedmore than 35 million death records for the years1979–94. The NDI had assisted 578 research projectsby performing 1,551 NDI file searches involving 18.2million records of study subjects.

Availability of vital statistics data

Vital statistics data are made available to thepublic in various forms, such as published volumesand reports, special tabulations, and more recently,electronic data products. The latter currently includepublic use data tapes and CD-ROM disks with theStatistical Export and Tabulation System (SETS)designer kit. Made available through these outlets arecounts of events, presentations of rates, ratios, actu-arial data, analyses, and discussions of quality, reliabil-ity, and methodology. Data obtained by the NationalNatality, Mortality, and Maternal and Infant HealthSurveys are made available in similar forms, as aredata from the National Survey of Family Growth.

Publications

Vital Statistics of the United States , bound annualvolumes that are distributed to many libraries for useby the public, have been published routinely, begin-ning with 1937 data and continuing to the presenttime. They contain numerous tables of detailed vitalstatistics and technical appendices explaining thesources and qualifications of the data.

Monthly Vital Statistics Report, a report of monthlyprovisional vital statistics, contains monthly and year-to-date statistics with comparative data for the preced-ing year. Supplements to the MVSR present annualsummaries of provisional data and of final data whenthey become available.

Vital and Health Statistics, intermittent seriesreports presenting data, analyses, and information ona wide variety of topics related to NCHS activities,include many reports emanating from the vital statis-tics program.

Public-use data tapes

Beginning with data for 1968, electronic data tapesare available for purchase containing natality, fetaldeath, marriage, and divorce statistics, as well asdemographic, underlying-cause, and multiple-causemortality statistics. Also available are data tapes ofthe linked files of live births and infant deaths begin-ning with data for the 1983 birth cohort, and of thenational follow-back surveys and the National Surveyof Family Growth. Measures are taken to protect theconfidentiality of individuals and prevent inadvertentdisclosure of confidential information. Public-use datatapes accelerate and enhance the availability of datato researchers and allow them to aggregate findings ina format appropriate for their analyses. The public-usedata tapes are purchased from the National TechnicalInformation Service.


CD-ROM with SETS

Linked files of live births and infant deaths for thebirth cohorts of 1985, 1986, 1987, and 1988 have beenproduced on CD-ROM using SETS. CD-ROM’s are alsoexpected to be available in 1996 for the 1989 through1991 linked files, for the 1991 fetal death and multiplecause-of-death files, and for the 1992 natality file. In1995, the 1991 telephone reinterview of respondents incycle IV of the National Survey of Family Growth wasmade available on CD-ROM using SETS, and in early1996, the 1991 longitudinal followup to the 1988National Maternal and Infant Health Survey was alsoissued on CD-ROM.

In 1996, a project was initiated to produce aCD-ROM that would enable users to derive frequen-cies, percentages, and rates for deaths in the UnitedStates for the data years 1969–93. This CD-ROM, alsoformatted and indexed using SETS, would includeaggregate numbers for selected variables (age, race,sex, county and State of residence, year of event, andcause of death for decedents), and thus it would bedifferent from the other CD-ROM’s just described,which contain individual respondent records. Also beingplanned was a similar CD-ROM for aggregate natalitydata to cover the same span of years and to includeinformation on such categories as age, race, birthorder, birthweight, prenatal care, education, maritalstatus, and State of residence for mothers of births inthe natality file. These aggregates would be retriev-able with the appropriate population denominators tocreate rates.

Vital statistics in the 21st century:A vision for the future

As the National Vital Statistics System approachesits centennial anniversary, it faces a number of chal-lenges. The historical system is based primarily onpaper recording of more than 6 million annual birthand death events by thousands of physicians, hospi-tals, funeral directors, and coroners. These records aretypically transmitted through local registration offi-cials, then keyed, queried, and edited as they arereceived by State offices. The data are transmittedperiodically to NCHS as files are completed. Afterlabor-intensive processing in both State offices andNCHS, the data are released to the public on anannual basis as reports or electronic products.

Over the last decade, NCHS and NAPHSIS havetaken significant incremental steps to improve thevital records system within its historical structure.Examples of these efforts include the electronic birthcertificate and refinements in automated coding. Thepursuit of these improvements has led to the conclu-sion that it is time to change the very nature of thesystem. NCHS and NAPHSIS have a vision for rein-

venting the vital statistics system for the 21st century.This vision requires not only automation, but a changein the basic relationships that exist among NCHS,State registration officials, and the providers of sourcerecords. The vision was first articulated by John E.Patterson (1992), then director of the NCHS Divisionof Vital Statistics, at the 1992 annual meeting of theVital Statistics Cooperative Program State ProjectDirectors. Since that time, it has been refined and is atthe beginning stages of implementation.

NCHS and NAPHSIS envision for the year 2000and beyond a vital statistics system in which birth anddeath certificates (and possibly other vital events) arecreated, edited, coded, queried, and corrected at thesource point in electronic form; transmitted over high-speed lines to a central location in each State for anyState processing and information management; andfinally, electronically transmitted to NCHS on a fre-quent and regular basis.

This redesign would create an information-management partnership between State vital statis-tics offices and NCHS. Data entry would be shiftedfrom the State office to the source data provider, whocompletes the original record; the original record wouldbe electronic rather than paper. Data entry wouldemploy standardized, automated editing systems tocontinually ‘‘clean up’’ the data by the States; changesand updates to the coded record would be transmittedto NCHS and entered in the data file on a continualbasis.

These changes would shift the focus of the vitalstatistics system from batch processing to dynamicprocessing and from an annual data release to acurrent-flow release as the data are received from theStates. Users could analyze the data, including anypreliminary or incomplete data that were availablewithin time-frames of their own choice. For somesurveillance purposes, timeliness may be much moreimportant than quality and completeness, and it willbe appropriate to use the most current data that areavailable. For some demographic and epidemiologicalanalyses, however, quality and completeness are ofparamount concern, and it may be necessary to waituntil the final annual files are available. All of thesteps that are required to produce a timely surveil-lance file on a current-flow basis will also contribute tothe timeliness and quality of the final data.

Many of these changes are already underway. In1995, almost 70 percent of births were registered elec-tronically (although most States were still processinga paper legal record). Experimentation with electronicdeath registration continues. In 1996, NCHS will beginto release 1995 data on a current-flow basis. Estimatesbased on 1995 records processed by March 1996 will bereleased for a variety of mortality and natality vari-ables and will provide detailed data never before avail-able this early. In future years, the release schedule

sis. Census Bureau. Vital statistics special reports 17(26).Washington: 1943.

8. Dunn HL, Shackley W. Comparison of cause of deathassignments by the 1929 and 1938 revisions of theinternational list, deaths in the United States, 1940.Bureau of the Census. Vital statistics special reports19(14). Washington: Department of Commerce. 1944.

9. Faust MM, Dolman AB. Comparability ratios based onmortality statistics for the fifth and sixth revisions:United States, 1950. National Center for Health Sta-tistics. Vital statistics—special reports 51(3). Washing-ton: Department of Health, Education, and Welfare.February 1964.

10. Faust MM, Dolman AB. Comparability of mortality sta-


will be adjusted as experience with the system isgained.

Vital records are the primary source of the mostfundamental public health information. Data on births,access to prenatal care, maternal risk factors, infantmortality, causes of death, and life expectancy areexamples of the types of information provided by vitalstatistics. Over the past 100 years, the national vitalstatistics system has matured into a program that canprovide complete and continuous information on issuesof importance to the Nation’s health. NCHS and itsState partners will continue to nurture and improvethe system as we move into the next century.

References1. Association for Vital Records and Health Statistics. A

history of the Association for Vital Records and HealthStatistics. 50th anniversary 1933–83. 1983.

2. Grove RD. The 1968 revision of the standard certifi-cates. National Center for Health Statistics. Vital healthstat 4(8). Washington: Public Health Service. 1968.

3. Dundon ML, Gay GA, George JL. The 1978 revision ofthe U.S. standard certificates. National Center for HealthStatistics. Vital health stat 4(23). 1983.

4. Tolson GC, Barnes JM, Gay GA, Kowaleski JL. The1989 revision of the U.S. standard certificates and reports.National Center for Health Statistics. Vital health stat4(28). Public Health Service. 1991.

5. Grove RD. Studies in the completeness of birth registra-tion. Bureau of the Census. Vital statistics special reports17(18). Washington: 1943.

6. Social and Economic Statistics Administration. Test ofbirth registration completeness, 1964 to 1968. 1970Census of population and housing. Bureau of the Cen-sus. Washington. 1973.

7. Woolsey TD. Description of methods used in the construc-tion of variation charts for the current mortality analy-

tistics for the sixth and seventh revisions: United States,1950. National Center for Health Statistics. Vitalstatistics—special reports 51(4). Washington: Depart-ment of Health, Education, and Welfare. March 1965.

11. Klebba AJ, Dolman AB. Comparability of mortality sta-tistics for the seventh and eighth revisions of the Inter-national Classification of Diseases, United States.National Center for Health Statistics. Vital health stat2(66). Washington: Department of Health, Education,and Welfare. 1975.

12. Klebba AJ, Scott JH. Estimates of selected compara-bility ratios based on dual coding of 1976 death cer-tificates by the eighth and ninth revisions of theInternational Classification of Diseases. National Cen-ter for Health Statistics. Monthly vital statistics report28(11) Supplement. Hyattsville, Maryland. PublicHealth Service. 1980.

13. Grove RD, Hetzel AM. Vital statistics rates in the UnitedStates, 1940–1960. Public Health Service. Washington.National Center for Health Statistics. 1968.

14. Lindner FE, Grove RD. Vital statistics rates in theUnited States, 1900–1940. U.S. Department of Com-merce. Washington. Bureau of the Census. 1943.

Appendixes

Contents

I. Appendix I tables

Table 1. Content of the U.S. standard certificate of live birth, by year revised . . . . . . . . . . . . . . . . . . . . . . 28Table 2. Content of the U.S. standard certificate of death, by year revised . . . . . . . . . . . . . . . . . . . . . . . . . 32Table 3. Content of the U.S. standard report of fetal death, by year revised . . . . . . . . . . . . . . . . . . . . . . . . 35Table 4. Content of the U.S. standard report of induced termination of pregnancy, by year

revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Table 5. Content of the U.S. standard license and certificate of marriage, by year revised . . . . . . . . . . . 39Table 6. Content of the U.S. standard certificate of divorce, dissolution of marriage, or

annulment, by year revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

II. History and Organization of the Vital Statistics System

Historical development . . . . . . . . . . . . . . . . . . . 43Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Beginnings: First use of records . . . . . . . . . 44From records to statistics . . . . . . . . . . . . . . 45Impact of industrialism . . . . . . . . . . . . . . . . 46Beginnings of modern registration . . . . . . 46State registration in America . . . . . . . . . . . 47The Shattuck report . . . . . . . . . . . . . . . . . . . 48Shattuck and the census of 1850 . . . . . . . . 48Registration and public health:1850 to 1872 . . . . . . . . . . . . . . . . . . . . . . . . . 48

Founding of the APHA and the NationalBoard of Health . . . . . . . . . . . . . . . . . . . . . 49

Leadership by the Census Office: 1880 to1890 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

The revolution in preventive medicine . . . 50Advances in disease classification . . . . . . . 51Census leadership after 1900 . . . . . . . . . . . 51Division of Vital Statistics: The road toreorganization . . . . . . . . . . . . . . . . . . . . . . . 53

Changing needs for vital records andstatistics . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Budget Bureau’s recommendations:1943 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Wartime cooperative arrangements . . . . . . 56Transfer to the Public Health Service:1946 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Growth of the birth- and death-registrationareas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Marriages, divorces, and notifiablediseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Marriages and divorces . . . . . . . . . . . . . . . . . 59Notifiable diseases. . . . . . . . . . . . . . . . . . . . . . 61

The vital records and statistics system . . . . . 63Registration and reporting activities . . . . . . . 63Registration of births . . . . . . . . . . . . . . . . . . 63Registration of deaths . . . . . . . . . . . . . . . . . . 63Registration of fetal deaths (stillbirths) . . . 63Registration of marriages and divorces . . . 64

Vital statistics organization . . . . . . . . . . . . . . . 64In local areas . . . . . . . . . . . . . . . . . . . . . . . . . . 64In the States . . . . . . . . . . . . . . . . . . . . . . . . . . 65In the United States. . . . . . . . . . . . . . . . . . . . 66

Appendix II tables

Table 1.01. Important dates in the history of birth and death registration: United States . . . . . . . . . . . 58Table 1.02. Growth of the birth- and death-registration areas: United States . . . . . . . . . . . . . . . . . . . . . . 58Table 1.03. Year in which each State was admitted to the birth-registration area . . . . . . . . . . . . . . . . . . 59Table 1.04. Year in which each State was admitted to the death-registration area . . . . . . . . . . . . . . . . . . 59Table 1.05. Sources of marriage and divorce totals: United States, 1867–1950 . . . . . . . . . . . . . . . . . . . . . 60Table 1.06. Year in which the central filing of marriage and divorce records began. . . . . . . . . . . . . . . . . . 60

Figure

Flow of vital records and statistics in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

27

Appendix I

Table 1. Content of the U.S. Standard Certificate of Live Birth, by year revised

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1979 1989

Birth information

Name of child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XSex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XDate of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XTime of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X – – X X XPlace of birth:Name of hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X –Name of facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XStreet and number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X – – – – – – – –If birth occurred in hospital or institution, give itsname instead of street number . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X – – – – – –

Type of place of birth (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XStreet and number if not in hospital . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X XTownship of, or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – –Village of, or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – –City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – –City, town, or location of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X XInside city limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – X X – –If outside city or town limits, write rural . . . . . . . . . . . . . . . . . . – – – – – X X – – – –County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XWard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – –

Birth weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – X X X X XSingle, twin, triplet, etc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XBirth order if not single birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XApgar Score:1 minute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X X5 minutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X X

Mother transferred prior to delivery . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XInfant transferred prior to delivery . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – X

Mother information

Maiden name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X X X X X X –Maiden surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XFull name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – – – – – XAge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X –Date of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XBirthplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X – – – – – – – –Birthplace (State or country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X X X X X XBirthplace (city or place) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X – – – – –Mother’s stay before delivery:In hospital or institution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X – – – – –In this community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X – – – – –

Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – –State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X XCounty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X XCity, town, or location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X XStreet and number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X XInside city limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – X X X XIf rural, give location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X – – – –Is residence on a farm? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – X – – –

Mother’s mailing address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X – X – X XHispanic origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XRace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X X X

28

Table 1. Content of the U.S. Standard Certificate of Live Birth, by year revised—Con.

Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1979 1989

Mother information—Continued

Legitimate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – X X X – –Mother married? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X – – – X XOccupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – –Usual occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X – – – – –Nature of industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X – – – – –Date (month and year) last engaged in this work . . . . . . . . . . – – – – X – – – – – –Total time spent in this work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –

Father information

Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XAge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X –Date of birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XBirthplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X – – – – – – – –Birthplace (State or country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X X X X X XBirthplace (city or place) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X – – – – –Hispanic origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XRace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X X XResidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – –Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – –Usual occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X – – –Nature of industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X X X – – –Date (month and year) last engaged in this work . . . . . . . . . . – – – – X – – – – – –Total time (years) spent in this work . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –

Pregnancy information

Pregnancy history:1

Live births, now living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XLive births, now dead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X X X X X XBorn dead (stillborn, fetal death) . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X – X X – –Born dead after 20 weeks pregnancy . . . . . . . . . . . . . . . . . . . . – – – – – – X – – – –Other terminations (spontaneous and induced):Under 20 weeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Over 20 weeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –

Other terminations (spontaneous and induced atany time after conception) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XDate of last live birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X X XDate of last fetal death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –Date of last other termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X X

Whether born alive or stillborn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X – – – – – –Cause of stillbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –Stillbirth––before labor or during labor . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –If stillborn, period of gestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –Clinical estimate of gestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XDate last normal menses began . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X X XLength of pregnancy (completed weeks) . . . . . . . . . . . . . . . . . . – – – – – – X X – – –Months of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X – – – – –Premature or full term . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –Month of pregnancy prenatal care began . . . . . . . . . . . . . . . . . . – – – – – – – – X X XNumber of prenatal visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X X XConcurrent illnesses or conditions affecting thepregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Medical risk factors for this pregnancy(checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XOther risk factors for this pregnancy (smoking,alcohol use, weight gain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XComplications not related to pregnancy . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –Complications of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Complications related to pregnancy . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –Complications of labor and/or delivery . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Complications of labor and/or delivery (checkboxes) . . . . . . . – – – – – – – – – – XComplications of labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –Obstetric procedures (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XMethod of delivery (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XAbnormal conditions of the newborn (checkboxes) . . . . . . . . . – – – – – – – – – – XCongenital malformations or anomalies of child . . . . . . . . . . . . – – – – – – – – X X –Congenital anomalies of child (checkboxes) . . . . . . . . . . . . . . . – – – – – – – – – – XBirth injuries to child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –

Appendix I 29


Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1979 1989

Certification information

Signature of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XType of attendant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X – –Date signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X XDate on which given name was added . . . . . . . . . . . . . . . . . . . . X X X X X X X X – – –Name of registrar adding given name . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X – – –Name and title of attendant at birth if other thancertifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Name and title of attendant if other than certifier(checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XMailing address of attendant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XName and title of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Name and title of certifier (checkboxes) . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XName of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –Mailing address of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X X –Address of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X – – –Signature of registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X XRegistrar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – –Date received by registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Date received by local registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X – –Date filed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – XSignature of parent or other informant . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X XInformant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X – –Relation to child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X – – X X –Nature of industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X X X – – –Date (month and year) last engaged in this work . . . . . . . . . . – – – – X – – – – – –Total time (years) spent in this work . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –


Pregnancy history:1

Live births, now living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XLive births, now dead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X X X X X XBorn dead (stillborn, fetal death) . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X – X X – –Born dead after 20 weeks pregnancy . . . . . . . . . . . . . . . . . . . – – – – – – X – – – –Other terminations (spontaneous and induced):Under 20 weeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Over 20 weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –

Other terminations (spontaneous and induced at anytime after conception) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XDate of last live birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X X XDate of last fetal death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –Date of last other termination . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X X

Whether born alive or stillborn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X X – – – –Cause of stillbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –Stillbirth––before labor or during labor. . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –If stillborn, period of gestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –Clinical estimate of gestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XDate last normal menses began . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X X XLength of pregnancy (completed weeks) . . . . . . . . . . . . . . . . . . – – – – – – X X – – –Months of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X – – – – –Premature or full term . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – – –Month of pregnancy prenatal care began . . . . . . . . . . . . . . . . . . – – – – – – – – X X XNumber of prenatal visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X X XConcurrent illnesses or conditions affecting thepregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Medical risk factors for this pregnancy (checkboxes) . . . . . . . – – – – – – – – – – XOther risk factors for this pregnancy (smoking, alcoholuse, weight gain) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XComplications not related to pregnancy . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –Complications of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Complications related to pregnancy . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –Complications of labor and/or delivery . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Complications of labor and/or delivery (checkboxes) . . . . . . . – – – – – – – – – – XComplications of labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –Obstetric procedures (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XMethod of delivery (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XAbnormal conditions of the newborn (checkboxes) . . . . . . . . . – – – – – – – – – – XCongenital malformations or anomalies of child . . . . . . . . . . . . – – – – – – – – X X –Congenital anomalies of child (checkboxes) . . . . . . . . . . . . . . . – – – – – – – – – – XBirth injuries to child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –

30 Appendix I


Item 1900 1910 1915 1918 1930 1939 1949 1956 1968 1979 1989

Certification information

Signature of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X X XType of attendant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X – –Date signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X XDate on which given name was added . . . . . . . . . . . . . . . . . . . . . X X X X X X X X – – –Name of registrar adding given name . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X – – –Name and title of attendant at birth if other thancertifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Name and title of attendant if other than certifier(checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XMailing address of attendant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – – XName and title of certifier. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Name and title of certifier (checkboxes). – – – – – – – – – – XName of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X – –Mailing address of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X X –Address of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X – – –Signature of registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X X XRegistrar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – –Date received by registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X –Date received by local registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X – –Date filed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – – XSignature of parent or other informant. . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X XInformant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X – –Relation to child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X – – X X –

1Prior to 1939, the pregnancy item included the birth registered. Beginning with 1939 the birth being registered is excluded.

X Indicates item included on standard certificate.– Indicates item not included on standard certificate.

Appendix I 31

Table 2. Content of the U.S. Standard Certificate of Death, by year revised

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 1989

Decedent information

Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XName of decedent (in margin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XSex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XRace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XHispanic origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XAge:Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XMonths/Days. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XHours/Minutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X X X X X X

Date of birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X XBirthplace:State or country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X –City, town, or county . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – –City or town. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – – – – –City and State or country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X

Citizen of what country. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X –How long in U.S., if of foreign birth . . . . . . . . . . . . . . . . . . . . . . . – – X X X – – – – –Marital status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XSurviving spouse (if wife, give maiden name) . . . . . . . . . . . . – – – – – – – X X XName of husband or wife . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X X – – – – –Age of husband or wife, if alive . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X – – – – –Was decedent ever in U.S. Armed Forces?. . . . . . . . . . . . . . . – – – – – – X X – XIf yes, give war or dates of service . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X – – –If veteran, name war . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – –Social Security number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XOccupation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – –Usual occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XName of employer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X – – – – – – –Business or industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X X X X X XDate deceased last worked at this occupation . . . . . . . . . . . . – – – X – – – – – –Total time (years) spent in this occupation . . . . . . . . . . . . . . . . – – – X – – – – – –Residence:Former or usual residence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – – – – – – – –State. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XLength of residence in the State (years, months, anddays) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – – – – –County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XCity, town, or location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XIf nonresident, give city or town and State . . . . . . . . . . . . . – – X X – – – – – –Ward. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – – – – –Street and number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X X X X X X XInside city limits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – X X X –Zip code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X

Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XFather’s name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XBirthplace of father:State or country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – –City or town. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – – – – –City, town, or county . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – –

Mother’s maiden name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XBirthplace of mother:State or country . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – – – – –City or town. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – – – – –City, town, or county . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – –

Place of death information

County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XCity, town, or location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XInside city limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – X X – –Township of, or. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – –Village of, or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – –City of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – –Ward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – –Street and number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – –Name of hospital or other institution . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X –Name of facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XIf hospital or institution indicate whether dead on arrival,outpatient/emergency room or inpatient . . . . . . . . . . . . . . . . – – – – – – – – X –If death occurred in a hospital or institution, give itsname instead of street and number . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – –If not in hospital or institution, give street address orlocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X X

32 Appendix I

Table 2. Content of the U.S. Standard Certificate of Death, by year revised—Con.

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 1989

Place of death information—Continued

Type of place of death (checkboxes) . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XLength of stay in hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – –Length of stay in this community . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – –Length of stay where death occurred . . . . . . . . . . . . . . . . . . . . X X X X – X X – – –Length of residence in the State . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – – – – –

Medical certification

Cause of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – –Duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X – – – – – – –Date of onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X – – – – – –

Immediate cause of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XInterval between onset and death . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X X

Due to, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XInterval between onset and death . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X X

Due to, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XInterval between onset and death . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X X

Due to, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XInterval between onset and death . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X

Contributory cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – –Duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X – – – – – – –Date of onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X – – – – – –

Other significant conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XDuration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – –Interval between onset and death . . . . . . . . . . . . . . . . . . . . . . – – – – – X – – – –

Was autopsy performed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – X X X X XWere autopsy findings considered in determining causeof death? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – X – –Were autopsy findings available prior to completion ofcause of death? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XWhat test confirmed diagnosis?. . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – – – – –Major findings of autopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – –Did an operation precede death? – – X – – – – – – –Date of operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – X – – – –Name of operation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X – – – – – –Major findings of operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X – – – –

Where was disease contracted if not place of death? . . . . X X X – – – – – – –For deaths from external causes:Accident, suicide, homicide, undetermined, or pendinginvestigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X –Accident, suicide, homicide, or undetermined . . . . . . . . . . – – – – – – – X – –Accident, suicide, or homicide . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X X X – – –Manner of death (checkboxes):Natural, accident, suicide, homicide, pendinginvestigation, could not be determined. . . . . . . . . . . . . . – – – – – – – – – X

Date of injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X X X X XTime of injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X XHow injury occurred. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X XInjury at work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XPlace of injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X X X X XLocation of injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X X X X X X XMeans of injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – –Manner of injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X – – – – – –Nature of injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X – – – – – –Was disease or injury related to occupation? . . . . . . . . . . . . . – – – X – – – – – –If so, specify . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X – – – – – –

Certifier:Signature and title of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X –Title (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XLicense number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X

Separate medical examiner or coroner certification. . . . . . . – – – – – – – X X XDate signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X – X X X X X XDate of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XTime of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XDate pronounced dead. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – X X XHour pronounced dead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – X X –Name of attending physician, if other than certifier . . . . . . . – – – – – – – – X –Name of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – X X XAddress of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X X XDates physician attended decedent. . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X – –Date last seen alive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X – –Did physician view body after death? . . . . . . . . . . . . . . . . . . . . . – – – – – – – X – –Was case referred to medical examiner or coroner?. . . . . . – – – – – – – – X X

Appendix I 33

Table 2. Content of the U.S. Standard Certificate of Death, by year revised—Con.

Item 1900 1910 1918 1930 1939 1949 1956 1968 1978 1989

Medical certification—Continued

Pronouncing physician:Signature and title . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XLicense number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XDate signed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X

Disposition information

Burial, cremation, or removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X –Method of disposition (checkboxes). . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – XDate of burial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X X – –Place of burial or removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – – – – – – – –Place of burial, cremation, or removal . . . . . . . . . . . . . . . . . . . . – – X X X – – – – –Name of cemetery or crematory . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X –Location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X X X X XName of cemetery, crematory, or other place . . . . . . . . . . . . . – – – – – – – – – XSignature of funeral director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – X – –Signature of funeral service licensee or person actingas such . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X XLicense number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – – X

Name of funeral director (or person acting as such) . . . . . . X X X X X X X – – –Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X – – –

Name of facility (funeral home) . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – X X XAddress of facility (funeral home) . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – X X X

Other information

Informant’s signature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – – – – –Informant’s name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – X X X X XMailing address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – X X X XRegistrar’s signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X X XRegistrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – –Date received by local registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X X – –Date received by registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – – – X –Date filed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – – – – X


34 Appendix I

Table 3. Content of the U.S. Standard Report of Fetal Death, by year revised

Item 1930 1939 1949 1956 1968 1978 1989

Fetal death information

Name of fetus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – –Sex of fetus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X XDate of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X XHour of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X –Place of delivery:Name of hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X X –Name of facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XState. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –If birth occurred in hospital or institution,give its nameinstead of street number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Street and number if not in hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X XTownship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Village . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –City, town, or location of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X X XInside city limits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X – –If outside city or town limits, write rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – –County of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X XWard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –

Weight of fetus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X X X XSingle, twin, triplet, etc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X XOrder if not single delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X X

Mother information

Mother’s name (first, middle, last). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XMaiden name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – –Maiden surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XAge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X –Date of birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XBirthplace (State or country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – –Birthplace (city or place) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – – – – –Length of stay in hospital or institution before delivery. . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –State. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X X XCounty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X X XCity, town, or location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X X XStreet and number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X X XInside city limits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X XIf rural, give location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X – – – –Is residence on a farm? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X – – –Zip code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – X

Mother’s mailing address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –Race . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X XHispanic origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X XLegitimate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – X X X – –Mother married? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – X XTrade, profession, or particular type of work done . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Usual occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –Occupation worked during last year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XKind of business or industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – – – – XDate (month and year) last engaged in this work X – – – – – –Total time (years) spent in this work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –

Father information

Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X XAge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X –Date of birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XBirthplace (State or country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – –Birthplace (city or place) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – – – – –Hispanic origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XRace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X XEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X XResidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Trade, profession, or particular type of work done . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Usual occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X – – –Occupation worked during last year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XKind of business or industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X – – XDate (month and year) last engaged in this work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Total time (years) spent in this work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –

Appendix I 35

Table 3. Content of the U.S. Standard Report of Fetal Death, by year revised—Con.

Item 1930 1939 1949 1956 1968 1978 1989


Pregnancy history:1

Live births, now living. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X XLive births, now dead. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X X XBorn dead (stillborn, fetal death) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – X X – –Born dead after 20 weeks pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X – – – –

Other terminations (spontaneous and induced):Under 20 weeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X –Over 20 weeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X –

Other terminations at any time after conception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XDate of last live birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X XDate of last fetal death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – –Date of last other termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X XWhether born alive or stillborn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Month of pregnancy prenatal care began . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X XNumber of prenatal visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X XPhysician’s estimate of gestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X –Clinical estimate of gestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XIf stillborn, period of gestation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Length of pregnancy (completed weeks). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – –Date last normal menses began . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X XMonths of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –Premature or full term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Concurrent illnesses or conditions affecting the pregnancy . . . . . . . . . . . . . . . . . . . – – – – – X –Complications not related to pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – –Complications of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – X –Complications related to pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – –Complications of pregnancy and labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X – – – –Medical risk factors for this pregnancy (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XOther risk factors for this pregnancy (smoking, alcohol use, weight gain) . . . . – – – – – – XComplications of labor and/or delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X –Complications of labor and/or delivery (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XComplications of labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – X – –Obstetric procedures (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XMethod of delivery (checkboxes). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XWas labor induced?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –Congenital malformations or anomalies of fetus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X –Congenital anomalies of fetus (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XWas there an operation for delivery? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –State all operations, if any . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X – – – –Did the child die before operation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –During operation?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –

Birth injuries to fetus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – X – –

Medical certification information

Cause of stillbirth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Fetal causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X – – – –Maternal causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X – – – –

Cause of fetal death:Immediate cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X XWhether fetal or maternal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X XDue to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X XWhether fetal or maternal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X XDue to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X XWhether fetal or maternal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X X X

Other significant conditions of fetus or mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X XWhen fetus died:Before labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – X X X XDuring labor or delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X XDuring labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – – – – –Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X X

Was autopsy performed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X X X –If yes, were autopsy findings considered?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – –

Signature of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – – X – –Date signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – –Title of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – – – – –Address of certifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – – X – –Signature of attendant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – –Date signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – –Title of attendant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X X – –Address of attendant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – –Name of physician or attendant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X –

36 Appendix I

Table 3. Content of the U.S. Standard Report of Fetal Death, by year revised—Con.

Item 1930 1939 1949 1956 1968 1978 1989

Medical certification information—Continued

Name and title of attendant (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – – XSignature of authorized official if not attended by physician – – X X X – –Statement of local registrar or coroner if physician not present. . . . . . . . . . . . . . . – X – – – – –Signature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –Title . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –

Disposition information

Burial, cremation, or removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X – –Date of burial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X X – –Place of burial or cremation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –Name of cemetery or crematory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X X – –Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X X – –

Signature of funeral director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – X – –Name of funeral director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X – – –Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X – – –

Name of funeral home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – –Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – X – –

Other information

Name of person completing report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X XTitle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – – – X XInformant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X – – –Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – – – – –Signature of registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X X X – –Date received by local registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X X – –Date filed with local registrar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – – – – –Date given name added . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –Signature of registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – – – – –

1Prior to 1939, the pregnancy history item included the event being registered. Beginning with 1939, the event being registered is excluded.

X Indicates item included on standard report.– Indicates item not included on standard report.

Appendix I 37

Table 4. Content of the U.S. Standard Report of Induced Termination of Pregnancy, by year revised

Item 1978 1989

Place of induced termination

Name of facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XAddress (if not hospital or clinic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XCity, town, or location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XCounty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X

Induced termination information

Date of pregnancy termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XPrevious pregnancies:Live births––now living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XLive births––now dead. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XOther terminations––spontaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XOther terminations––induced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X

Date last normal menses began . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XPhysician’s estimate of gestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X –Clinical estimate of gestation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – XComplications of pregnancy termination:None . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X –Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X –Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X –Uterine perforation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X –Cervical laceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X –Retained products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X –Other (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X –

Type of termination procedures:Procedure that terminated pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XAdditional procedures used. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XSuction curettage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XSharp curettage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XIntra–uterine saline instillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XIntra–uterine prostaglandin instillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XHysterotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XHysterectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XDilation and Evacuation (D&E) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – XOther (specify) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X

Patient information

Patient identification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XAge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XMarital status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XResidence:State. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XCity, town, or location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XInside city limits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XCounty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – XZip code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X

Race (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XHispanic origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X

Other information

Name of attending physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X XName of person completing report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X

X Item included on standard report.– Item not included on standard report.

38 Appendix I

Table 5. Content of the U.S. Standard License and Certificate of Marriage, by year revised

Item 1956 1968 1978 1989

Groom information

Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XAge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X XDate of birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XRace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XUsual residence:State. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCounty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCity, town, or location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XStreet and number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X –Inside city limits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – –

Birthplace (State or foreign country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XMarital status:Number of this marriage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XNumber of previous marriages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – –Previous marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – –How last marriage ended . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XDate last marriage ended. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X

Father’s name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XBirthplace (State or foreign country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X

Mother’s maiden name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XBirthplace (State or foreign country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X

Occupation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – –Business or industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – –

Bride information

Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XMaiden name if different . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XAge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X XDate of birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XRace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XUsual residence:State. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCounty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCity, town, or location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XStreet and number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X –Inside city limits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – –

Birthplace (State or foreign country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XMarital status:Number of this marriage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XNumber of previous marriages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – –Previous marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – –How last marriage ended . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XDate last marriage ended. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X

Father’s name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XBirthplace (State or foreign country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X

Mother’s maiden name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XBirthplace (State or foreign country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X


License information

Signatures of applicants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – –Date signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – –Groom’s signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X XBride’s signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X XDate license was subscribed and sworn to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X XSignature of issuing officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X XTitle of issuing officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X XExpiration date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X

Ceremony information

Date of marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XPlace of marriage:State. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – –County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X

Appendix I 39

Table 5. Content of the U.S. Standard License and Certificate of Marriage, by year revised—Con.

Item 1956 1968 1978 1989

Ceremony information—Continued

Person performing ceremony:Title . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X XSignature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XName . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – XReligious or civil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – –Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X

Date signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – –Type of ceremony––religious or civil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X –Witnesses to ceremony––signatures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X X

Other information

Signature of local official making return to State health department . . . . . . . . . . X X X XDate received by local official . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X –Date of recording . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X – – –Date filed by local official . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X


40 Appendix I

Table 6. Content of the U.S. Standard Certificate of Divorce, Dissolution of Marriage, or Annulment, by year revised

Item 1956 1968 1978 1989

Husband information

Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XDate of birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XRace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XUsual residence:State. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCounty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCity, town, or location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XStreet and number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X –Inside city limits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – –

Birthplace (State or foreign country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XMarital status:Number of this marriage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XIf previously married, how many ended by death? divorce?. . . . . . . . . . . . . . . . – X X –If previously married, last marriage ended by death, divorce,dissolution, or annulment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – XDate last marriage ended. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X


Wife information

Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XMaiden surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – XDate of birth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XRace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XUsual residence:State. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCounty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCity, town, or location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XStreet and number. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X –Inside city limits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – –

Birthplace (State or foreign country) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XMarital status:Number of this marriage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XIf previously married, how many ended by death? divorce?. . . . . . . . . . . . . . . . – X X –If previously married, last marriage ended by death, divorce,dissolution, or annulment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – XDate last marriage ended. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X


Decree information

Date marriage was dissolved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XType of decree––divorce, dissolution, or annulment . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XDate of entry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X –Date recorded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – XCounty of decree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XTitle of court . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X XTitle of court official . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X –Signature of certifying court official . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XTitle of certifying official . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XDate signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – XParty to whom decree granted. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – –Legal grounds for decree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – –Petitioner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X –Petitioner (checkboxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – XPlaintiff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X – –Attorney for petitioner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X XAddress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X X

Attorney for plaintiff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – –Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – –

Number of children whose physical custody was awarded to:husband, wife, joint (husband/wife), other, or no children . . . . . . . . . . . . . . . . . . . – – – X

Appendix I 41

Table 6. Content of the U.S. Standard Certificate of Divorce, Dissolution of Marriage, or Annulment, by year revised—Con.

Item 1956 1968 1978 1989

Other information

Place of this marriage:State or foreign country. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCounty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XCity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – X –City, town, or location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X

Date of this marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X XDate couple separated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X X –Date couple last resided in same household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – XNumber of children ever born alive of this marriage . . . . . . . . . . . . . . . . . . . . . . . . . . – – X –Living children in this family. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – X – –Children under 18 in this family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X X X –Number of children under 18 in this household as of the datecouple last resided in same household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – – – X


42 Appendix I

Appendix II

History and Organization ofthe Vital Statistics System

Historical Development

s isedof

mpnerint

IntroductionMore than 7,000,000 birth, death, marriage, and

divorce certificates were recorded in 1950. Many orga-nizations and many millions of citizens used theserecords—or certified copies of them—for a variety ofpersonal, legal, health, and other purposes. Vital sta-tistics derived from the records were part of the fac-tual basis for a great segment of the private and publicbusiness transacted in the United States. They enteredinto the planning and operation of health programs,social welfare, education, economic enterprises (rang-ing from life insurance to the marketing of babies’toys), and a broad gamut of other activities essential tothe well-being and prosperity of the country.

Behind the original records, the certified copies,and the vital statistics is a network of local, State, andFederal agencies. The purpose of this section is to tellhow the vital records and statistics system of theUnited States was begun and developed, how its orga-nization, concepts, and practices were continuouslyshaped by the growth and changing needs of thecountry. At various stages, new social institutions oradvancing technology, particularly in the field of health,created new demands for records and statistics, andsometimes changed the emphasis and motivating drivesof the system itself.

This is a reproduction of a document that firstappeared in the Vital Statistics of the United States,Volume 1, 1950, pp. 1–19.

NOTES: This review of the rise of American registration and vital statisticbased on a limited survey of original and secondary sources. It is ventura beginning, in the hope that it will at least set forth the main linesdevelopment so as to give registration and vital statistics personnel a gliof their heritage, provide educational material for the schools and the gepublic, and encourage students with a gift for research in history to digthe subject matter more deeply.

An effort has been made to tell as a narrative the development ofregistration and vital statistics down to about 1900. The more recentstory is presented more briefly, as a series of high lights.

Most people take vital statistics for granted, assum-ing that any statistics they need should be freelyavailable as part of today’s culture. What distin-guishes the men of today from those who lived beforethe American Revolution is that ‘‘we have all learnedto talk in size language,’’ as Lancelot Hogben puts it.‘‘We live in a welter of figures: cookery recipes, railwaytime-tables, unemployment aggregates, fines, taxes,war debts, overtime schedules, speed limits, bowlingaverages, betting odds, billiard scores, calories, babies’weights, clinical temperatures, rainfall, hours of sun-shine, motoring records, power indices, gas-meter read-ings, bank rates, freight rates, death rates....’’1

Death rates are among the typical vital statisticsthat most people assume we have always had availableand, without much effort, will continue to have. The realstory is quite different: national statistics of deaths andbirths were achieved only within the present generation,after two centuries of intermittent struggle and building.Marriage and divorce statistics are still incomplete andrelatively primitive. Progress in registration and vitalstatistics has been part of the general advance of scienceand medicine, which developed by relying on measure-ments and other quantitative procedures. Medicine andthe public health movement flourished by adopting themethods of science, by resorting increasingly to quanti-tative techniques. Among the most fruitful of these werethe basic measurements of vital statistics. In turn, vitalstatistics were developed primarily because medicineand public health actively promoted and helped build theregistration system that makes vital statistics possible inthis country.

In recent years, as vital statistics became moreprecise—more comparable from place to place andfrom one period of time to another—they were betterable to serve the general and specialized demographicneeds of business, civil and military branches of gov-ernment, social research and welfare, and the generalpublic. In the broad spectrum of needs served by

as

sealo

1. Hogben, Lancelot, ‘‘Mathematics for the Million,’’ p. 20, New York, 1940.

43

44 Appendix II

modern vital statistics, the band occupied by healthand medicine, though still the most important seg-ment, is only a part of the whole.

In some ways the American system is unique; thereasons for its particular course of development lie inthe historic past. In colonial days, when a handful ofsettlements clung precariously to the eastern edge ofthe continent, many of our institutions borrowed heavilyon the experience of our forefathers before they emi-grated from England and other countries. Hence someof the roots of our present vital statistics system beganin foreign soil. Some of the major roots lie in thebeginnings of America itself—in the fact that Virginia,New England, Delaware, the Carolinas, Georgia, Penn-sylvania, New Jersey, and other settlements weresponsored by more or less independent British compa-nies or patrons; that when control of the Coloniespassed to the Crown they were ruled by separate royalgovernors; and that when they won independence theyturned, by the nature of their past life and condition-ing, to a federal rather than a centralized government,so that the federated States were self-governing in allmatters not expressly conferred on the national gov-ernment by the Constitution.

To apportion the Congressional representation ofeach State according to its population, the Statesprovided in the Constitution itself for the decennialcensus. Hence, throughout the course of its develop-ment in this country, the census has been a nationalfunction. The need for vital statistics, on the otherhand, was unrecognized when the Constitution wasframed, and the vital records and statistics systemdeveloped originally not as a national undertaking,but first as a local, then as a State function. Thishistoric accident, which makes the course of Americanvital statistics so different from that of countries wherethe function is national like the census, posed enormousdifficulties, and undoubtedly slowed its development bymany decades. At the same time, because American vitalregistration grew in response to local and State needs, ithas support and sources of strength that might be lack-ing if the system were primarily national.

In practice, for the past century, American vitalstatistics and the census have worked hand in hand.Until recent years, the national functions in vitalstatistics were in fact lodged in the Census Bureau.Between census data and vital statistics, thoughthey continuously supplement and enrich each otherin practice, there are two essential differences. First,the census is based on enumeration—a periodiccount of the population and its characteristics madeby canvassers in house-to-house interviews; vitalstatistics, on the other hand, are derived from vitalrecords, which record events that occur to individu-als. The second difference is that the census isdecennial; vital records are made continuously, asthe events occur. This second difference was described

in vivid terms by Walter F. Willcox, a former ChiefStatistician in the Washington Census Office:

A census is a sort of social photograph of certainconditions of a population at a given moment which areexpressible in numbers, while registration is a continuous,contemporary, movie-camera record of births, marriages,divorces, or deaths. . . . In theory the two are inseparable; acensus system which does not flower into registration isalmost as fruitless scientifically as capital which does notfructify in income. As the life of an animal or plant cannotbe studied from a series of photographs alone showing thestages of its growth, so the life of the American peoplecannot be studied from a series of censuses unaided byregistration.2

Beginnings: First use of recordsThe settlers were predominantly English, and for

the most part followed English customs in the newcountry. They were accustomed to the registration ofchristenings, marriages, and burials, which in Englanddated back to 1538, when the clergy in all parisheswere first required to keep a weekly record of suchevents. In 1632, the GrandAssembly of Virginia passeda law requiring a minister or warden from everyparish to appear annually at court on the 1st of Juneand present a register of christenings, marriages, andburials for the year. These were the traditional eventsconducted by the church, but in effect they provided anaccount of births, marriages, and deaths.

Apparently little or no statistical use was madeof such records, and there was certainly no thoughtof using them for health purposes. In the beginning,the records were regarded primarily as statementsof fact essential to the protection of individual rights,especially those relating to the distribution of prop-erty. The emphasis on vital records as legal docu-ments to protect both the individual and thecommunity is clear in the pronouncement of theGeneral Court or legislative body of the Massachu-setts Bay Colony in 1639:

Whereas many judgments have been given in ourCourts, whereof no records are kept of the evidence andreasons whereupon the verdict and judgment did pass,. . . itis therefore by this Court ordered and decreed that henceforward every judgment, with all the evidence, be recordedin a book, to be kept to posterity. . . that there be recordskept of all wills, administrations, and inventories, as also ofevery marriage, birth, and death of every person within thisjurisdiction.

While this law was based on the English prece-dent, it differed in two important respects: the respon-sibility was placed on government officers rather than

2. Willcox, Walter F., ‘‘Studies in American Demography,’’ p. 195, New York,1940.

Appendix II 45

the clergy; and it called for the recording of vitalevents—births, deaths, and marriages—rather thanchurch-related ceremonies. Connecticut and Ply-mouth, and eventually other colonies, followed a simi-lar pattern.

Thus, at the basis of the vital registration systemwas the principle that the records are legal statementsof fact that help assure the rights of individuals asconferred by organic laws. Machinery was set up tocollect and preserve the records, not at first for statis-tical reasons, but because authentic evidence wasessential to the just administration of law and theprotection of individual rights.

With this obligation in mind, Massachusetts (andother colonies) repeatedly strengthened the early reg-istration laws. In 1644, it added a penalty clause forfailure to report vital events, and in 1692, in the mostcomprehensive registration act in the period, it empow-ered town clerks to collect threepence from the next ofkin for each birth or death, to fine individuals forfailure to report, and to charge sixpence for ‘‘a faircertificate.’’ A century later, in 1795, it required par-ents to inform the town clerk of births and deaths ofchildren, householders to give notice of those in theirhouseholds, and institutions to report births and deathsoccurring in them.

None of the early registration laws was particu-larly effective. Although a few cities and towns main-tained active registration, for many years not a singleState could be said to have a system covering its entirearea. Permanent legal records, justified largely bytheir use as evidence of property rights, seemed unim-portant to a footloose population undergoing rapidchange. Eastern seaboard cities were swelled by immi-grants, many of whom stayed only long enough to hearthe call of the western frontiers.

Registration needed a new and more impellingimpetus. It was to receive one in the dawning realiza-tion by a few gifted statisticians and medical men thatrecords of births and deaths, particularly records ofdeaths by cause, were needed for the control of epidem-ics and the conservation of human life through sani-tary reform.

From records to statistics

Bills of mortality—consisting of parish lists ofinterments, usually including cause of death and ageof deceased—had been compiled in England for morethan a century before any effort was made to analyzethem. Towards the end of the 16th century, when anepidemic of plague gripped the city, bills of mortalitywere published in London to restore public confidence.Vital statistics in the modern sense has been said totake its origin from the publication, in 1662, of ‘‘Natu-ral and Political Observations Mentioned in a Follow-

ing Index, and Made Upon the Bills of Mortality,’’ byJohn Graunt of London (1620–74). Despite the meager-ness of his material, Graunt discerned that vital eventsoften follow regular patterns, for example, that malebirths exceed female births, that deaths at the begin-ning of life are relatively high, etc. This demonstrationthat general truths about the population could bederived from vital records stimulated further analysisboth in Britain and in the European continent. Theastronomer EdmundHalley (1656–1742), applyingmath-ematical techniques developed in other fields, con-structed the first scientific life expectancy table in 1693.

Death records of some sort were apparently keptby American settlements from the earliest days. At theoutset, disease ranked with starvation as a threat tothe existence of many of the colonies. Malaria, dysen-tery, and typhoid fever usually decimated settlers onnew clearings. Smallpox, which was brought by thesettlers themselves, and yellow fever which came inwith the Negro slaves, brought repeated devastation.The toll of the recurrent epidemics is detailed insources such as Winthrop’s Journal, various lists of theparish dead complied by the clergy, and burial returnsmade to town officers by cemetery sextons.

One of the earliest uses of such records for statis-tical purposes was made in 1721 by the clergyman,Cotton Mather, who noted during a severe smallpoxepidemic in Boston that more than one in six of thenatural cases died but only one in sixty of the inocu-lated cases. This is a sophisticated use of statistics,and it is evident that simple records of death bycertain causes were available much earlier.

Parallel to the growth of early registration efforts,but mostly unconnected at first, was sporadic rise oflocal health or sanitary boards, usually in response toan acute epidemic. During the 17th century and mostof the 18th, there was probably no permanent organi-zation in English America to promote public health.Outbreaks of disease were met as emergencies, buteventually the larger cities established boards ofhealth as the forerunners of the modern local healthdepartments. Baltimore, in 1793, and Philadelphia,in 1794 (in response to a yellow fever epidemic thatkilled one-eighth of its population), established thefirst two local boards. Massachusetts enacted thefirst State law authorizing the creation of localboards in 1797. From various meager indications, itappears certain that from the very early days thehealth officers began scanning the burial returns orweekly lists of interments and roughly compilingthem in statistical reports. These vital statisticsprecursors were used—though the extent is difficultto determine—as a means of identifying and combat-ing epidemics, and as a means of reporting healthconditions to the community.

In Baltimore, for example, death records havebeen collected and compiled by the health department

bythrthouovisofsh

.

,

46 Appendix II

since 1797; annual reports, containing lists of deathsby causes, have been issued since 1817. The earlyreports from time to time called the community’sattention to an unusually large number of deaths froma particular disease.3

Impact of industrialism

Meanwhile, one of the great pivotal changes inhuman history was gathering force. It would be over-simplication to pick a single date as the beginning ofindustrialism and the swift growth of manufacturingcenters. But by 1800, it was obvious that the socialorder was changing, and that the change was bringingwith it a train of new problems that the social organi-zation and technology of the time were not equipped tohandle. With rapid urbanization came a dramaticincrease in slums, crime, and poverty. In England,which was the first country to industrialize, thought-ful men expressed alarm at the overcrowding of cities,the filth and polluted water, and at the abject miserythat seemed to be overtaking the poorer classes. Epi-demics of old and new diseases struck repeatedly. Thereformers of the time groped for whatever vital andhealth statistics they could get in order to arouse thenational conscience to a sanitary awakening.

On the European continent, starting first in France,the industrial revolution brought the same evils andthe same reactions. Pierre Louis (1787–1872), in anepoch-making series of studies starting in 1825, intro-duced rational medical statistics to clinics and generalphysicians. Louis Villerme (1782–1863) adapted thestatistical approach to public hygiene, and in 1828showed that the condition of neighborhoods was relatedto disease in Paris and the French provinces. Statisti-cal study of disease and its causes, based on the crudevital statistics of the time and any other data avail-able, began to be used increasingly on the continentand in England as a weapon of sanitary and socialreform. It was time for a new weapon, since medicaland sanitation practices—such as imperfect quaran-tine measures—which had seemed adequate for anearlier day, were proving powerless against cata-strophic epidemics of typhus, yellow fever, and chol-era. This last disease, which by the 1830’s had spreadfrom Asia through Russia to Germany to the British

3. But it was not until 1875, when death certificates were first requiredBaltimore law, that any consistent use was made of statistical methods ordeath rates by cause were regularly compiled. Similarly, records of live biwere not kept until 1875, and birth registration was very defective until ab1915. The Baltimore history should be particularly illuminating to studentsregistration because of the thorough study made by Dr. William TraHoward, Jr., ‘‘Public Health Administration and the Natural HistoryDisease in Baltimore, Maryland, 1797–1920,’’ Carnegie Institution of Waington, D.C., 1924.

Isles and to Canada and the United States, was obvi-ously related to bad sanitary conditions.

According to Shryock,

After 1831 there was a sudden increase of interestthroughout Europe and America in the whole problem ofpublic hygiene. Fear now combined with humanitarianismto demand investigations, cleanups, and general sanitaryreform, as these things had never been demanded before.Whenever enthusiasm waned, further invasions of cholera,supplemented by occasional outbreaks of yellow fever,typhoid, typhus, and smallpox, terrified authorities intorenewed activity. In these circumstances is to be found thegenesis of the modern public-health movement.4

Beginnings of modern registrationThe general circumstances that led to action against

disease led inevitably to revived interest in perfectingvital registration and vital statistics. The crude data ofthe time were used with telling effect to characterizepublic health problems, to chart the course of epidemics,and to show the influence of dirt and poverty on diseaseand death. But in country after country, the early sani-tarians became aware of their need for more precisestatistics, and some of them expressed this need directlyby pressing for effective and comprehensive registrationlaws. Here again it was apparently the fear of cholerathat paved the way for legislative action.

Panic was a large factor in securing repentance andgood works when cholera threatened; as it, likewise, was inan earlier century when plague became epidemic; and inboth instances the desire for complete and accurate infor-mation as to the extent of the invasion led in England to thecall for accurate vital statistics. It may truly be said that theearly adoption of accurate registration of births and deathswas hastened by fears of cholera, and by the intelligentrealisation that one must know the localisation as well asthe number of the enemy to be fought.5

In England, Edwin Chadwick (1800–1890), secre-tary of the Poor-Law inquiry commission, had been ledinto the study of vital statistics, and then into thegeneral field of public health, by his need for mortalitystatistics in connection with voluntary insuranceschemes. Chadwick was apparently influenced by Vil-lerme in a series of investigations that led in the early1830’s to the reform of the poor laws and of child laborconditions in the cotton mills. Chadwick also strove toestablish national registration of deaths, since differ-ences in mortality by area or social group were thekind of vital statistics he could use effectively tohammer for sanitary reform.at

stf

-

4. Shryock, Richard Harrison, ‘‘The Development of Modern Medicine,’’ p221, New York, 1947.

5. Newsholme, Sir Arthur, ‘‘Evolution of Preventive Medicine,’’ p. 113Baltimore, 1927.

Appendix II 47

The English-speaking world lagged in vital registra-tion during this period. According to Willcox, in 1833 theregions in which deaths and births were routinely regis-tered comprised less than one-tenth of the world’s popu-lation. They covered about 80 million people in France,Belgium, Austria, Prussia, Bavaria, Saxony, the Scandi-navian countries with Finland and five cities in theUnited States, containing only 6 percent of the country’spopulation. The five cities were Boston, New York, Phila-delphia, Baltimore, and New Orleans.

The inadequacy of vital statistics in England—andthe spur of a devastating cholera epidemic in 1831–32which took nearly 42,000 lives in Great Britain andIreland—led in 1836 to enactment of a registrationlaw creating a central register office with responsibil-ity for the records and statistics of births, marriages,and deaths—by cause—for all of England and Wales.According to one authority, the act was written byChadwick who ‘‘took the details and even the phras-ing’’ from Jeremy Bentham’s ‘‘Constitutional Code.’’6

This act was an historic turning point in thedevelopment of registration and public health not onlyin England but in the United States and many otherparts of the world. According to Shattuck in 1850 (seefootnote 8), this registration law was the ‘‘most impor-tant sanitary (public health) measure ever adopted inEngland; and it has been the foundation of nearly allothers. Without it they would have been comparativelyof little value.’’

From this time forward, the course of registra-tion and vital statistics was to be recognized as basicto the development of public health organization andpractice. Part of the motivation for the act was toimprove vital records as legal documents ‘‘for thesecurity of property,’’ but its main orientation was tocollect the facts on births, deaths, and disease as abasis for striking at the appalling sanitary condi-tions of the time. In 1839, Dr. William Farr (1807–83), whom Raymond Pearl called ‘‘the greatestmedical statistician who has ever lived,’’ joined theRegister Office as ‘‘compiler of abstracts.’’ Farr com-piled vital statistics to present the human cost ofsickness and premature death, in a series of bril-liant reports which, in Newsholme’s words, ‘‘haveguided sanitary reform and incited it year by year toincreased activity.’’ Benjamin Ward Richardson saidof Farr’s reports that ‘‘it is no longer true thatpestilence walketh in the dark.’’

State registration in AmericaThe impact of Chadwick, Farr, and the Act of 1836

on vital statistics in the United States was immediate,specific, and far-reaching. Chadwick inspired Lemuel

6. Political Science Quarterly, vol. 38, p. 45 ff., 1923.

Shattuck of Massachusetts (1793–1859), whose influ-ence on American registration and the public healthmovement is probably second to none; Farr’s statisticalingenuity in the use of vital data to point up publichealth problems stimulated Shattuck and others in thiscountry; and the Act of 1836 was the prototype of thefirst State registration law in America, which Massachu-setts adopted in 1842 and strengthened in 1844.

Shattuck was the prime mover. He used the Ameri-can Statistical Association, which he largely foundedin 1839, to induce both the American Academy of Artsand Sciences and the Massachusetts Medical Societyto petition the legislature for an effective registrationlaw. The act that Shattuck finally steered through thelegislature in 1844 required central State filing; pro-vided for standard forms, fees, and penalties; specifiedtypes of information including causes of death; andlodged responsibility for each kind of record in desig-nated officials.

The National Medical Convention, which soon orga-nized formally as the American Medical Association(AMA), channeled medical interest in registration in1846 by creating a committee to consider methods forimproving birth, marriage, and death registration. Ayear later the newly formed AMA addressed memorialsto State legislatures on the need for registration laws.

It was probably about this time that local vitalstatistics, which previously had been used mostly bysanitary and social reformers, gradually came intoroutine use by local health officers as a practical guide.The best described example is that of John Simon(1816–1904), who was appointed first Medical Officerof Health in London in 1848, ‘‘the prototype of ourmodern health officer, the first health officer in themodern sense.’’7 According to Round, ‘‘For John Simon,vital statistics formed the corner-stone of his work.’’

Where did Simon get his information regarding theconditions prevailing at the moment and upon what infor-mation did he base his acts as medical health officer? FromSimon’s book on English Sanitary Institutions we find thatthe death returns of the city registrars were made onMonday mornings and on Monday afternoons they wereplaced at his disposal, as he says, ‘‘in a way which enabledme to complete my use of them during the evening, so thaton Tuesday mornings when the weekly courts of the CityCommission were held, I was ready with all needfulparticulars as to the deaths which had befallen the citypopulation during the previous week, and with my schemeof such local inquiries as were to be made in consequence.’’

During this period, Great Britain and variouscountries on the continent, thanks to small land areasand a central form of government, carried through

7. Round, Lester A., ‘‘Consumer Demand for Vital Statistics: The HealthOfficer’s Point of View,’’ American Journal of Public Health, vol. 26, p. 489,May 1936.

or’ p

48 Appendix II

national investigations of health conditions, and cre-ated new health and registration institutions on thebasis of the results. The developing United States,with its vast and largely unexplored land area and itsFederal-State rather than central form of government,could not be expected to progress as rapidly on anational scale. However, the new American MedicalAssociation made an important contribution by exam-ining conditions of the larger American cities. In 1848,it reported that disease was as prevalent in Boston,New York, and Philadelphia as in London, Manches-ter, and Glasgow, and that the death rates were evenhigher in the American cities. These revelations, plusthe example of Massachusetts, prompted six addi-tional States to enact registration laws by 1851, thoughfor the most part the laws were ineffective and unen-forced.

The Shattuck reportIn 1850, Shattuck presented to the legislature his

epochal ‘‘Report of the Sanitary Commission of Massa-chusetts,’’ described by C.-E.A. Winslow as ‘‘one of themost remarkable documents—perhaps the most signifi-cant single document—in the history of public health.’’8

In fifty specific recommendations, including the cre-ation of a State board of health whose program was tobe based solidly on complete registration and vitalstatistics, Shattuck anticipated nearly all the publichealth measures (except those based on the still unbornscience of bacteriology) which the next two generationswere to introduce. Actually, nearly 20 years were toelapse before Shattuck’s detailed plans were to beadopted as the health department organic law of Mas-sachusetts, and then to be widely emulated in otherStates. These developments will be treated below inchronological sequence.

Shattuck and the census of 1850Meanwhile, in 1849, the Superintendent of the

United States Census, to improve the still-primitivecensus practice and to make a start toward collectingthe first national vital statistics, invited Shattuck toWashington to help draw up plans for the SeventhFederal Census. In his brilliant ‘‘Census of Boston forthe Year 1845,’’ which Willcox has called ‘‘the pioneeramong modernAmerican censuses,’’ Shattuck had intro-duced the basic innovation of making the primarycensus unit the individual rather than the family.Instead of describing the whole family on a single line,he had given a line on the schedule to each person,

8. Shattuck, Lemuel, and others, with a Foreword by Charles-Edward AmWinslow, ‘‘Report of the Sanitary Commission of Massachusetts, 1850,’VII, reprinted, Cambridge, 1948.

which made it easy to record the name, age, birth-place, marital condition, and occupation, and toassemble the data afterward in new and more reveal-ing types of tables. For the 1850 Federal census,Shattuck wrote five of the six schedules as well as theenumerators’ instructions. According to Willcox, ‘‘Themost important improvements during 150 years ofFederal censuses resulted from the adoption in 1850 ofShattuck’s ideas.’’

Against his better judgment and over his protest,Shattuck also introduced the practice of using censusenumeration to determine births, marriages, anddeaths. Unalterably convinced that only a registrationsystem would provide such information, Shattuckdeferred to the census officials to include the items‘‘Born within the year,’’ ‘‘Married within the year,’’ and‘‘Disease, if died within the year.’’ It was hoped thatthe resulting vital statistics would be better thannone, but the official report later admitted:

The tables of the census which undertake to give thetotal number of Births, Marriages, and Deaths, in the yearpreceding the first of June, 1850, can be said to have butvery little value. Nothing short of a registration system inthe States can give the required data satisfactorily, and ithas been proved that even where such systems have beenbest established, difficulties continually arise which requirea very long time to be removed. Experience has shown thatpeople will not, or cannot, remember and report to thecensus taker the number of the facts, and the particulars ofthem which occur in the period of a whole year to eighteenmonths prior to the time of his calling.9

(Despite its obvious defects as a method for collect-ing national vital statistics, census enumeration ofvital events was not entirely abandoned until thecensus of 1910, when the developing registration areawas large enough to provide better national statistics.In defense of the census officials who persisted for 50years in a discredited method, it must be said that theregistration system was not ready to take over anyearlier, and the choice was vital statistics by enumera-tion or no national data at all.)

Registration and public health:1850 to 1872

During the period 1850 to 1860, registration wasworking well in a handful of cities and in two States.In the rest of the country, particularly in rural areas, itwas too sporadic to afford vital statistics in the modernsense. In an attempt to improve the situation, theAmerican Medical Association in 1855 adopted thefollowing resolutions:

y. 9. DeBow, J. D. B., ‘‘Statistical View of the United States . . . Being aCompendium of the Seventh Census,’’ p. 57, Washington, D.C., 1854.

ita

oftheheogy

Appendix II 49

RESOLVED, That the members of the medical profes-sion throughout the Union be urgently requested to takeimmediate and concerted action for petitioning their severallegislative bodies to establish offices for the collection ofvital statistics.

RESOLVED, That a committee of one from eachState be appointed to report upon a uniform systemof registration of marriages, births, and deaths.

This action was probably spurred by the very highmortality rates which marked the decade. Since thebeginning of the century, to judge from the imperfectstatistics of the time, city death rates had been climb-ing to appalling levels. Immigration filled the urbantenements and overtaxed the rudimentary sanitaryfacilities. In Chicago, for example, typhoid deaths in1854 were recorded at a rate of 175.1 per 100,000population. In New York City, total deaths rose from21.5 per 1,000 population in 1810 to 36.8 in 1857.10

Meanwhile, a number of physicians and sanitar-ians had been considering the idea of a national publichealth association. As early as 1851, Wilson Jewell ofthe Philadelphia Board of Health began planning sucha group, and in 1857 he and others were able toorganize the National Quarantine and Sanitary Con-vention. Annual meetings were held until 1861, whenthe Convention was disrupted by the Civil War. Meet-ing ostensibly to consider quarantine regulations, thegroup invariably went beyond these to promote broadplans for sanitation, and paid much attention to vitalstatistics and the need for improved registration.

By this time, the health field was divided into twoopposing camps. In the one were the believers in‘‘contagion,’’ who were convinced that epidemic diseaseentered the country mainly through the ports, and wasspread by infected animals or persons. This camptherefore advocated seaboard quarantine and isolationof the sick. In the other camp were those who lookedfor the causes of disease in their own (and theirneighbors’) backyards—in the filth, miasms, and nox-ious odors of the crowded cities. This was the sanitarygroup, which tried to fight disease with clean streets,clean water, garbage collections, sewage disposal, andso on. To locate the sore spots, for example, to find thetyphoid sources to clean up, the sanitary school placedgreat stress on vital statistics, and used ‘‘before andafter’’ figures as educational material to promote fur-ther reform.11

The Civil War probably delayed public health andregistration by several years, but did both movements

10. Proceedings and Debates of the Third National Quarantine and SanConvention, p. 523, New York, 1859.

11. In retrospect, depending on the disease and the actual circumstancesspread, it is clear that both camps were partly right and partly wrong. Butcontroversy flared up repeatedly, often with considerable ill-will, until t1890’s when the two groups were reconciled by the findings of bacterioland medical entomology, as described below.

some good—‘‘in spite of itself,’’ as Shryock put it.12 Anumber of physicians—notably John Shaw Billings(1838–1913), Medical Statistician of the Army of thePotomac—first became interested in public hygienewhen disease proved to be a deadlier enemy than theopposing army. After the War, Billings and others weredrawn increasingly into the public health movement.Typhoid fever had scourged both North and South, andmany of the returning soldiers were carriers. Thefantastically high infant mortality rates of the postwarperiod were taken as an index of bad health conditionsin general.

Massachusetts led the way to health reform byenacting, after 19 years’ delay, a comprehensive Statehealth law modeled on the Shattuck report. By 1872,the District of Columbia, California, and Virginia fol-lowed with similar legislation. Thus began a period ofrapid growth in State health organization, which inmost instances was to include registration and vitalstatistics as a regular health department function.

Founding of the APHA and theNational Board of Health

In 1872, a group of physicians and sanitarians,including many who had learned the value of statisticsin the wartime sanitary commissions, founded theAmerican Public Health Association (APHA). Takingup where the earlier Sanitary Conventions had left off,the APHA worked for an aggressive public healthprogram, based on sanitary reform with a strong vitalstatistics base as a principal component.

Following a disastrous yellow fever epidemic inthe South, Congress, in 1879, created the NationalBoard of Health, largely on the basis of plans advancedby the APHA. The leadership of the APHA and astrong group in the AMA, dissatisfied with the empha-sis placed on quarantine measures by the MarineHospital Service, had wanted a national agency thatwould work on a broader front—to centralize informa-tion, engage in sanitary research, and collect vitalstatistics.13 Despite some overlapping of functions andcompetitive activity between the Board and the MarineHospital Service (later the United States Public HealthService), the Board made important contributions. Notthe least of these was to advance the cause of vitalstatistics by placing extraordinary value upon com-plete and uniform vital registration. In its first year itestablished a standing committee, under Stephen Smith(first president of APHA), and later Billings, to pro-mote uniformity in registration. The weekly Bulletinry

its12. Shryock, Richard H., ‘‘The Early American Public Health Movement,’’American Journal of Public Health, vol. 27, p. 970, October 1937.

13. Leigh, Robert D., ‘‘Federal Health Administration in the United States,’’ p.468, New York, 1927.

pter.

50 Appendix II

of the Board undertook immediately to publish mortal-ity summaries from cities able to supply the informa-tion from vital records.

The difficulties of publishing national vital statis-tics at this time are apparent in every issue of theBulletin. For the year 1879, the Board received annualmortality reports, or weekly reports for the full year,from 24 cities. Fourteen separate forms were repre-sented, ‘‘and of these no two are alike. The differencesare such as to render direct comparison in some casesimpossible, and difficult in all. Not only is there nouniform plan as to nomenclature, classification, orarrangement, but a most ingenious diversity existsas to the selection or omission of the several items ofinformation usually expected in such reports.’’14 Butthe rapid effect of the Board’s promotional activitymay be seen in the fact that, by March 1880, it wasreceiving weekly mortality reports from an averageof 90 cities, with improvement in the quality ofreporting.

In the second year of its existence, the Boardcalled a national meeting of State and local registrars(May 1880) to consider the best methods for collectingand publishing vital statistics, and took up such ques-tions as standard nomenclature for assigning causes ofdeath, comparability of vital records, and problems ofobtaining complete registration. As part of the prepa-ration for this meeting, and as a regular functionduring its brief existence to 1883, the Board collectedand published information on State and local registra-tion laws, forms, tables, reports, and registration pro-cedures and methodology, and from time to time itrecommended standard models. As a coordinator andpromoter of vital statistics, the Board (mainly throughBillings) had an immediate impact on the perspectivesand methods of the Census Bureau, which for morethan a half-century was to carry on and extend thework in registration which the Board had begun.

Leadership by the Census Office:1880 to 1890

Billings, while still chairman of the National Boardof Health’s Committee on Vital Statistics, was placedin charge of the 1880 census of mortality. The firstthree census counts of deaths (1850, 1860, 1870) hadfallen short of actual deaths by 40 percent. Under anamendment to the census law of 1880, the Superinten-dent of the Census could withdraw mortality sched-ules and accept registration records from any areashaving records in satisfactory detail. At Billings’ sug-gestion, a so-called registration area was establishedin 1880, and registration records were obtained froman increasing number of States and cities in the

14. National Board of Health Bulletin, vol. 1, No. 36, March 6, 1880.

succeeding censuses.15 Billings also supplied physi-cians with books of blank death certificates, andrequested them to fill out a form for each death theyattended. The books were collected by the censustakers and were used to obtain information on addi-tional deaths or to improve the accuracy of deathreports received. Using 1880 data, Billings also pro-duced what were considered accurate life tables for 2States and 12 cities.

Before the 1890 census, the Census Office wrote toall States and cities having 5,000 population or moreto obtain an index of probable registration complete-ness. Experience with the 1880 census had demon-strated that laws governing death registration, degreeof enforcement of such laws, and the manner of obtain-ing and recording data were so varied that the process-ing of these records by the Census Office was difficultand subject to considerable error.

In an effort to obtain better and more uniformdata, the Census Office recommended a form of deathcertificate to be used in the 1890 census. In thatcensus, prompted by the thought that death and dis-ease are not subject to political boundaries, Billingsmade the first attempt to produce statistics by geo-graphic and climatic areas.

The Census Bureau, adapting machine techniquesused in the textile industry, used the Hollerith mechani-cal tabulator for the first time on a large scale opera-tion in the 1890 census. Rapid counting and combiningof characteristics could now be done with a highdegree of accuracy.

The revolution in preventivemedicine

During the 1880’s, medical science was trans-formed by a series of discoveries which were to changethe course and direction of the public health move-ment, and multiply its effectiveness against epidemicdisease. Koch isolated the comma bacillus of cholera,and Gaffky the organism of typhoid fever (1884).Theobald Smith and F. L. Kilborne opened the way tothe control of the arthropod-borne diseases, such asmalaria and yellow fever, by tracing Texas fever incattle to infected ticks (1889). In this period, Germanand French bacteriologists found the cause of diphthe-ria, and the causes of other diseases were soon added.These discoveries in disease etiology were accompa-nied by a series of triumphs in immunology, led by thegenius of Pasteur.

The sanitary reformers and the quarantiners foundin the new sciences a common meeting ground, andtogether put public health on a more rational basis.With exact knowledge came discriminating use of tra-

15. See separate section on birth- and death-registration areas in this cha

,

Appendix II 51

ditional and new means of disease control. By the1890’s, the best health departments were beginning toachieve dramatic results in preventive medicine. Tosupplement sanitation and quarantine, they begansetting up laboratories to diagnose disease and later toprovide typhoid vaccine and diphtheria toxin-antitoxin. Private medicine found in the new discover-ies more effective ways of curing the sick.

In all these developments, vital statistics weresharpened to keep pace, to point more precisely toproblem areas, and to demonstrate the value of thenew techniques in disease control. It was about thistime, for example, that comparative infant mortalityrates proved the life-saving value of pasteurization ofmilk, and induced the American dairy industry tomove toward modern sanitary methods.

Advances in disease classification

The march of bacteriology and other medical sci-ences helped also to revolutionize diagnosis, and indi-rectly to transform vital statistics (particularly,mortality by cause) into a more accurate and usefulhealth adjunct. From the time of Hippocrates (440–357 B. C.), physicians had with varying success triedto diagnose and classify disease by observing its natu-ral history and symptoms. This approach was carriedforward by the brilliant English clinician ThomasSydenham (1624–89), whose objective descriptions influ-enced medical practice and vital statistics until theywere at last overtaken by the precision-methods of thelaboratory. Meanwhile, vital statistics struggled alongwith the prevailing nosology or systematic classifica-tion of disease—which was not very systematic untilmuch later. By the second half of the 19th century,physicians were moving away from vague diagnoseslike ‘‘fever’’ and had identified a large number ofcommon diseases. The practice of making autopsiesand the advance of surgery after the discovery ofeffective anesthetics in the 1840’s led to better diagno-sis and classification of disease.

After 1850, steady progress was made in develop-ing an international classification of causes of deathand a standard nomenclature. As recommended by theAMA, the Census Office in the 1850 and 1860 censusesemployed a classification developed by Farr. In the1870 census, on the advice of the Surgeon General ofthe U.S. Army, the classification and nomenclature ofthe Royal College of Physicians of London in 1869were adopted.

Efforts were continued by the International Statis-tical Congress, from the 1850’s on, to produce anacceptable classification of causes of death. The UnitedStates was a member of this body; Billings, for example,met with the Congress in 1880. Within a few years, asnoted above, bacteriology upset the traditional means

of identifying many of the common diseases, and wasbeginning to break down various categorical diseasesinto two or more distinct entities. Thus, the advent ofbacteriology set off a parallel revolution in nosology,and in the resulting vital statistics. In 1898, the APHAformally adopted a modern classification which JacquesBertillon of France had prepared for the InternationalStatistical Institute. The APHA recommended thatthis list be revised periodically to keep abreast ofmedical science. Since then, the list has been reviseddecennially, on an international basis.

Census leadership after 1900When the census count of mortality was made in

1900, it seemed likely that a permanent Census Officewas to be established, and plans were made accord-ingly. Prior to the census, intensive correspondencewas carried on with each State and with cities of 5,000population or more. The Census Office collected dataand material on law, procedure, estimated rates, prob-able number of deaths not registered, etc., and releaseda circular to acquaint registration personnel with thefindings. It also recommended a death certificate andrequested each area to adopt it by January 1, 1900.Twelve States adopted the form in full; six States andthe District of Columbia adopted it in part; and seventy-one major cities in other States adopted the form infull or made revision. The census of 1900 includedfigures obtained from well-established registration areaswhich had adopted model laws and where it wasbelieved that 90 percent completeness of registrationhad been attained.

Marriage and divorce were also matters of publicconcern. In 1887, Congress passed an act directing theCommissioner of Labor to collect statistics on mar-riages and divorces for the years 1867 through 1886.16

In 1905, President Theodore Roosevelt sent a specialmessage to Congress in which he recommended that‘‘the Director of the Census be authorized by appropri-ate legislation to collect and publish statistics pertain-ing to that subject (marriage and divorce) covering theperiod from 1886 to the present time.’’17

Since 1880, the Census Office had consistentlyadvocated national uniformity in State supervision, inbasic procedures, and in the forms used for registra-tion of deaths. In the same period, interest in statisticsgenerally became widespread, and there appeared apublic disposition to consider statistical reporting agovernmental responsibility. The Census Office, whichhad previously been disbanded between censuses, was

16. Wright, Carroll D., ‘‘Marriage and Divorce in the United States, 1867 to1886,’’ Department of Labor, Washington, D. C., 1889.

17. U. S. Bureau of the Census, ‘‘Marriages and Divorces, 1867–1906,’’ p. 4U. S. Government Printing Office, Washington, D. C., 1909.

n

52 Appendix II

made a permanent, full-time agency of the FederalGovernment in 1902, and was given its present name,the Bureau of the Census.

The organic act provided statutory authority forregistration areas for births as well as deaths. Fromthis time forward, the Bureau completely abandonedthe 50-year effort to obtain mortality information bycensus counts, and relied solely upon registrationrecords. As its principal task, the Bureau undertook todevelop an annual system of collection of vital statis-tics data, capable of producing comparable statisticson a national basis. The over-all objective was todevelop and maintain a uniform system of registrationwith respect to such matters as law, forms, procedures,statistical methodology, etc.

It was recognized that these objectives wouldrequire the cooperation of outside organizations andthe public at large. Organizations that formed workingarrangements with the Bureau included the AmericanMedical Association, American Public Health Associa-tion, Conference of Commissioners on Uniform StateLaws, American Statistical Association, American BarAssociation, and the National Tuberculosis Association.

Among the more important steps initiated by theBureau were: formulation of principles and wording ofa model law; drafting of standard forms; preparationof instructions for local registrars, physicians, andothers; preparation of a system of mortality classifica-tion satisfactory for statistical purposes; formulationof rules of statistical practice; and establishment ofworking relationships with external groups within andoutside the country. As a working concept, the Bureauannounced that it would become a central office formortality statistics, act as a clearing house to harmo-nize the results of individual efforts in the variousState and city offices, and look forward to the possibil-ity of forming a national association of registrars.

In 1907, the American Public Health Associationestablished a Vital Statistics Section to develop closerworking relations among registration officials; to pro-mote more effective systems of vital statistics; to aidthe adoption of uniform registration methods and pub-lication of statistical data; etc. For many years theAPHA had been active in promoting uniform Stateregistration and model laws. At the annual meeting in1895, various members of the association proposedthat it either draft a model law or set forth principles.At its annual meeting in 1900, the APHA adoptedprinciples of a model law for the registration of birthsand deaths. Strong support for model State laws camefrom Congress, which on February 11, 1903, adopted ajoint resolution requesting State authorities to cooper-ate with the Census Bureau in securing a uniformsystem of birth and death registration. By 1907, amodel bill, which in 1905 had been adopted by Penn-sylvania in draft form, was submitted to the Stateswith the endorsement of a broad list of organizations.

The principles of this and subsequent model laws havesince been adopted in every State of the Union, eitherby direct enactment or by regulations.

The Federal Children’s Bureau, created in 1912,worked actively with the Census Bureau in many ofthe State campaigns. Credit should also be given tothe able leadership of William Alexander King, chiefvital statistician of the Census Bureau, 1900–1906,and Cressy L. Wilbur, who held the position from 1906to 1914. Through their efforts, uniform State legisla-tion advanced rapidly, and permitted an increasingnumber of States to qualify for admission to the death-registration area.

About 1913, the Census Bureau began appointingagents in the State health agencies, and authorizingthem to use the mailing privileges of Federal officials,to promote registration, and to correct the certificatesof birth and death which are the sources of the nationalstatistics.

In 1914, the Bureau published the first table sepa-rating nonresident from resident deaths; the data hadbeen lumped together up to that time. Although com-plete reallocation of deaths by place of residence wasnot yet possible, the first table was an important stepin this direction.

In 1915, the national birth-registration area wasformed. Before then, the collection and publication ofdata were limited to death records because they weremore complete, of greater public interest than birthrecords, and because it was believed that the concen-tration of census efforts in one field of registrationwould yield better results than if its efforts werespread thin.18

After the United States entered the First WorldWar, the need to provide health authorities with cur-rent information on epidemics became apparent.Largely as a war measure, the Census Bureau obtainedweekly telegraphic reports on the number of deathsand infant deaths occurring in cities of more than100,000 population. Beginning October 1917, this infor-mation, together with comparative death rates and theproportion of infant deaths to total deaths, was pub-lished in a Weekly Health Index, which was laterexpanded to include separate tabulations of influenzadeaths during the pandemic of 1918–19.

The wartime influx of workers into industrial cen-ters, and the growing tendency for serious illnesses ofout-of-town residents to be treated in urban hospitalsaggravated existing distortions in the crude deathrates of many cities and towns. During 1918, theBureau therefore sought to obtain complete data onthe ‘‘usual place of abode’’ of nonresidents who diedwithin the death-registration area. On the basis of this

18. Shapiro, Sam, ‘‘Development of Birth Registration and Birth Statistics ithe United States,’’ Population Studies, vol. IV, No. 1, June 1950.

rc

heal

the

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Appendix II 53

information, the Bureau published the first tables inwhich nonresident deaths were reallocated to place ofresidence. Deaths of nonresidents living outside theregistration area were shown separately.

Concerned with the slow growth of the registrationareas, the Bureau in 1924 established a committee tobring all States into the registration areas by 1930.The advice and assistance of many varied interestshelped advance this program. As a further stimulus, in1924 the Census Notification of Birth Registration wasdeveloped, to be mailed to parents from State vitalstatistics offices when they received certificates ofbirth. This offered parents an opportunity to verify orcorrect information contained in the birth record andhelped to promote registration generally.

The following excerpt from a report of the NationalResources Committee perhaps best summarized thisperiod:

The long, hard, often discouraging campaign whichwas fought to bring States, one by one, into the foldconstitutes one of the proudest chapters in the history of theBureau of the Census . . . . In some States, the boards ofhealth had to be educated to the need, before the citizens ofthat State could approach the legislature. In others, thelegislatures were apathetic, in spite of strong pressures.After the required legislation was passed, there remainedthe problem of bringing a State up to the minimum quota.Each State had to educate its physicians and undertakers asto their duties, as well as an army of local registrars. TheBureau aided the State registrars in preparing promotionalpublicity and facilitated the exchange of ideas as to themost effective ways of presenting public health data to thegeneral public.19

Division of Vital Statistics: The roadto reorganization

The social and economic forces that had beengenerated in the war and postwar periods workedfundamental changes in the patterns of American life.In December 1929, President Hoover appointed a groupof social scientists to make a national survey of socialtrends—to see what had happened to private economicorganization, government functions, public welfare,education, family patterns, the role of women in indus-try and the home, rural and metropolitan patterns,sports and other recreation, labor organization, and awide variety of the other interrelated institutions thatmake up American life as a whole and dictate the formof its social problems. The underlying social data,including vital statistics, came in for close scrutiny,particularly by Stuart A. Rice and his associates whoproduced several penetrating studies of the current

19. National Resources Planning Board, ‘‘Research—A National ResouPart I,’’ p. 210, Washington, D. C., 1938.

status and developmental needs of social statistics.20

Both assets and deficiencies were freely discussed, andimportant suggestions were made for improving Fed-eral vital statistics.

Much the same concern that had led to thesestudies was reflected in the actions of professionalorganizations. The Social Science Research Counciland the American Statistical Association, which wereboth interested in improving Federal statistics, com-bined their respective committees on social statisticsin a joint committee, with Professor Robert E. Chad-dock as chairman and Dr. Rice as secretary. Thoughconcerned mainly with social welfare data, this com-mittee had related interests in population and vitalstatistics.

Despite growing demands for improved and morecomprehensive statistics to cope with the Depression,sweeping reductions were made in government statis-tical services early in 1933, following the Economy Actof 1932. These cuts were vigorously protested, particu-larly when the swift expansion of government func-tions in the economic crisis created urgentadministrative needs for statistics as a factual basis ofdecisions and programs. In this situation, the need fora thorough reappraisal of government statistical ser-vices soon became widely recognized.

In the spring of 1933, the Secretaries of Agricul-ture, Commerce, Labor, and Interior invited the SocialScience Research Council and the American StatisticalAssociation ‘‘to furnish immediate assistance and advicein the reorganization and improvement of the statisti-cal and informational services of the Federal Govern-ment.’’ In response, the two organizations establisheda joint Committee on Government Statistics and Infor-mation Services (COGSIS), which began work in June1933 with financial support from the Rockefeller Foun-dation. Among many other activities, the COGSISmade a preliminary survey of the vital statistics of theBureau of the Census and the Public Health Service,which was completed in May 1934.21 This survey,which was begun during the summer of 1933 while Dr.Rice was acting chairman of the committee and whichcontinued in the fall when he joined the Census Bureauas assistant director, marked the beginnings of a dras-tic reorganization of the work of the Division of VitalStatistics.

For approximately a third of a century, the funda-mental task of the Bureau of the Census in the field ofvital statistics had been to extend the registration

e,

20. See, especially, Rice, Stuart A., and collaborators, ‘‘Next Steps in tDevelopment of Social Statistics,’’ and DePorte, Joseph V., ‘‘Guides to VitStatistics in the United States,’’ Volumes I and III in a Report to thePresident’s Research Committee on Social Trends on Social Statistics inUnited States, Ann Arbor, 1933.

21. See the final report of COGSIS, ‘‘Government Statistics,’’ Bulletin No. 26Social Science Research Council, April 1937.

54 Appendix II

area for births and deaths. With the completion of thebirth area by the admission of Texas in 1933, thisprimary responsibility was accomplished. The period1933 to 1935 was a time of appraisal and preparationfor new types of work for which the Bureau hadbecome responsible. These fell into two main catego-ries: (1) improvement of all reports for the completedregistration areas; and (2) research in the new fields ofvital statistics which had been opened.

For these tasks, the Division needed considerablestrengthening, both in number of personnel and pro-fessional training. After the 1930 census, the Bureauas a whole had made little progress in recruiting orholding professional personnel. In the Division of VitalStatistics only the chief statistician was at the profes-sionally classified level. While studies of means tostrengthen the Division were under way, an opportu-nity developed in the summer of 1934, with FederalEmergency Relief Administration Funds, to conduct acampaign in some 20 States to promote birth registra-tion. The COGSIS staff members helped organize thisprogram, which improved registration in nearly all theStates and furnished incidental data for checking onweak registration areas. The Committee also helpedthe Bureau to develop the reporting of births anddeaths by place of residence of mother or decedent,beginning January 1, 1935. This greatly improved thedata, which had previously been published mainly onthe basis of place of occurrence of the birth or death,and which had become distorted by the growing use ofcity hospitals by rural residents.

At the request of the Census Director, the COGSISsubsequently made a more intensive survey of theDivision and developed, among others, the followingrecommendations:

1. The Division should be strengthened by creat-ing office and field positions for several peoplewith professional degrees.

2. A permanent expert field staff should worksystematically to speed up and improve reliabil-ity of reporting in the States.

3. The feasibility of rewarding States for espe-cially meritorious cooperation, perhaps by cre-ating a new registration area, should beinvestigated.

4. A monthly reporting system using provisionalfigures on births should be established.

5. Systematic plans should be made for publica-tion of special monographic studies.

6. Revisions should be made in annual publishedvolumes providing for more analytical and inter-pretive text material, standardization of ratesfor age, tabulation by broad socio-economicgroups and certain selected occupational groups,more extensive tabulations by age groups, andomission of considerable costly and relatively

unimportant material, such as births by coun-try of birth of mothers.

In 1935, under the new leadership of Halbert L.Dunn, a physician and biometrician, the Division wasdrastically reorganized, and its professional staff greatlyaugmented. In the same year, the Secretary of Com-merce appointed an Advisory Committee for the Divi-sion of Vital Statistics, which at its first meetingrecommended that development of the Division shouldbe continued along the following broad lines:22

1. Extension of field work in order to secure andmaintain completeness and to improve complete-ness and accuracy of the data noted upon theoriginal certificates, and to promote cooperationbetween Federal, State, and nonofficial agenciesdealing with and interested in vital statistics.

2. Coordination of State and Federal statisticaloffice activities with the object of eliminatingoverlapping effort insofar as possible.

3. Development of means by which the total datain the birth and death certificate might bemade available for special public health andscientific needs.

4. Stimulation of research within the Division byappropriate cooperation of the Division withoutside scientific and public health agencies,and by building up within the Division a per-sonnel whose principal duties would be theanalysis and solution of important vital statis-tical problems.

Changing needs for vital recordsand statistics

By the early 1930’s, responsibility for vital recordshad been largely transferred from civil offices to healthdepartments. As more and more departments employedfull-time officers with public health training, theywere able to make more intensive use of the records forstatistical analysis. In addition to using statistics tolocate and deal with disease outbreaks, defective waterand sewage facilities, and related sanitation problems,many health departments routinely used them as thebasis for maternal, infant, and child care programs,immunization against childhood diseases, and a vari-ety of other personal health services. During the 1930’s,the emphasis in public health work shifted even far-ther away from the sanitation diseases, which by thenwere under control in most areas. Greater attentionwas paid to communicable diseases in which case-finding was the key to control. The Public Health

22. Dunn, Halbert L., ‘‘Development of Vital Statistics in the Bureau of theCensus,’’ American Journal of Public Health, vol. 25, No. 12, p. 1322,December 1935.

s—irthlaw ent

Appendix II 55

Service developed a national tuberculosis control pro-gram to supplement voluntary and State activities,and greatly expanded national control of venerealdiseases through technical and financial aid to theStates. In both programs, vital statistics were widelyused to map out areas and population groups in whichcase-finding efforts would be most fruitful. The needfor this kind of statistics had, in fact, been part of theimpetus for the reorganization of the Vital StatisticsDivision.

While these health needs for statistics continued,the records suddenly became important to large num-bers of individuals, who for the first time in their liveshad to prove vital facts about themselves.23 Beginningabout 1935, Federal and State Governments enacted avariety of welfare legislation, such as old age and othersocial security. As a result of new directions in labor-management relations, the movement toward indus-trial pension plans became widespread. The commonfactor in both the public and private plans was the useof the birth certificate as a legal document to evidencethe fact of age.

A few years later, the outbreak of World War IIproduced an additional shift in emphasis. Congresswrote into law provisions against the employment ofaliens in certain defense projects, so that for the firsttime the birth certificate was widely demanded asevidence of citizenship. Early in 1940, State officeswere hard pressed to fill requests for birth certificatesof persons seeking employment in defense industries.Since many of these births had never been registered,the problem of filing delayed birth certificates becameacute. It was estimated that nearly 55,000,000 nativepersons who were living in 1940 had no birth record onfile. Some States did not have express provision in lawor regulation governing delayed certificates. The rulesand standards in operation in other States varied andwere complex, since uniform standards for filing hadnot been formulated.

The Division of Vital Statistics was called upon byState registrars to aid in the development of accept-able standards. Successive meetings of Federal agen-cies and State representatives resulted in a set ofrecommendations which were incorporated in a Manualof Uniform Procedures for the Delayed Registration ofBirths, issued by the Bureau of the Census on July 16,1941. Procedures for delayed registration were adoptedimmediately by a large number of States, but the goalof uniform principles was not fully achieved.

When the United States entered the War, theconversion to all-out war production and the drive toemployment in war plants started in earnest. In addi-

23. An earlier instance of the use of birth certificates for legal purposeperhaps the first since colonial days—occurred after World War I when bcertificates began to be used extensively in the enforcement of regulatorydealing with child labor and compulsory education.

tion, separate legislation increased the need for certifi-cates, for example, the emergency maternal and infantcare program for dependents of service men. Almostimmediately, State registrar offices were swamped bythe wholesale demand for birth certificates, often bypersons born before the establishment of records sys-tems. Many State and local offices abandoned statisti-cal functions to prepare certified copies and to devisemeans of providing delayed birth certificates for per-sons whose births had not been registered.

To meet these needs the States reacted with vari-ous types of emergency legislation, deviating widelyfrom the model laws which had been providing a fairdegree of national uniformity. Needs for certificateswere met in diverse ways, and standards acceptable inone State proved either too lenient or too strict inanother. Federal agencies requiring such certificateswere bewildered by the variety of standards, andpressures began to mount for a return to greateruniformity. The difficulties encountered by State vitalstatistics offices and by applicants for certified copiesled to a series of proposals, numerous bills in Con-gress, and a general feeling that something drasticwould have to be done.

Budget Bureau’s recommendations:1943

In July 1942, the President of the United Statesurged Congress not to enact any hasty legislation. Inthe same letter, he acknowledged ‘‘great confusion invital records growing out of the activities of govern-ment and industry, particularly in connection with thesecurity and health laws.’’ In view of the need forstudy, the Budget Bureau at his request made its ownsurvey, and examined the recommendations of an offi-cial Commission on Vital Records headed by Dr. Low-ell J. Reed, and a report adopted by the Association ofState and Territorial Health Officers.24

The report of health officers, which foreshadowedthe Budget Bureau’s recommendations, had warnedagainst solutions offering purely financial relief to theStates, solutions that might undermine the work ofexisting registration agencies, and solutions that woulddilute the standards and thus weaken the value ofvital records. Instead it proposed the creation of acooperative vital records system, comprising the exist-ing State and independent city vital statistics officesand a national office to ‘‘represent and serve thesystem from a Federal standpoint, and, by makingavailable financial and technical aid, would work toimprove, develop, and integrate the individual units ofthe system.’’ It called for a program of continuous

s24. Measures Relating to Vital Records and Vital Statistics, House DocumNo. 242, Washington, D. C., 1943.

nd

56 Appendix II

allotment of money to the present State, city, andTerritorial offices to be spent for correcting defects inthe registration system and for expansion as required.

The objective of the national office would be ‘‘tocorrect the deficiencies now existing on a national,State, and local basis, in the coordination and stan-dardization of vital records agencies, methods, andrequirements.’’ In addition, the plan provided for thetransfer of Census Bureau functions in vital statisticsto a bureau or division of the United States PublicHealth Service. The report noted that ‘‘assuranceshave been given by officers of the United States PublicHealth Service that, if functions of the Division ofVital Statistics are transferred to the United StatesPublic Health Service, the Vital Records Office willhave the responsibility and authority to work out incooperation with the other bureaus and divisions ofthe United States Public Health Service, and Stateand other Federal officers, whatever future programsmay be mutually desirable and beneficial.’’

On the basis of these studies, the Budget Bureaurecommended against legislation to authorize Federalagencies to issue documents as substitutes for birthcertificates. On the positive side, it recommended:

That a national vital records office should be estab-lished as a separate organizational unit in the United StatesPublic Health Service, the head of the office to reportdirectly to the Surgeon General.

This office should work with and through theexisting State and local vital statistics agencieswith a view to developing a record system which,while nationwide in scope, will preserve the whole-some responsibility of the State and local govern-ments. The proposed office should not only assumethe functions of the present Division of Vital Statis-tics of the Bureau of the Census but should also beauthorized to take appropriate steps (within theframework of normal Federal-State relationships)to promote higher standards of performance withinand better coordination among the State and localvital records agencies.

The recommendations of the Budget Bureau, theCommission, and the Association of State and Territo-rial Health Officers were in essential agreement on theneed for a cooperative vital records system with thecoordinating responsibility placed in a single nationalagency. Thus, the report was a major turning point inthe position of the Federal Government in vital recordsand statistics. While the Census Bureau had beenresponsible for publishing vital statistics, and hadworked with vague authority to coordinate practices inthe independent State offices, no Federal agency hadever been explicitly charged with responsibility for thevital records system.

At that time the Budget Bureau estimated thatthe Federal Government was spending $2 million ayear, and the State and local agencies $6.5 million, for

vital records and vital statistics. In addition, the pub-lic was paying a total of perhaps $12 million in fees togovernment agencies and others for services in obtain-ing documentary evidence. Despite these substantialexpenditures, the Budget Bureau found that Americanvital records were ‘‘surprisingly inadequate.’’ Visits toseveral State vital records offices showed that thewartime volume of demands for certification was notbeing met promptly and adequately, and that in divert-ing personnel to the certification problem the Stateswere neglecting the long-run task of seeing that allcurrent births and deaths were promptly and accu-rately registered. ‘‘It cannot be assumed,’’ the Bureaudeclared, ‘‘that needs for adequate vital records willdisappear after the war emergency is ended; on thecontrary, the course of social evolution points to con-tinually increasing needs for official records of theexistence, identity, and status of individuals, and forstatistics based on such records.’’

Wartime cooperative arrangementsPending Executive or Congressional action on the

Budget Bureau’s recommendations, the Division ofVital Statistics continued to work toward a coordi-nated system, but under special handicaps imposed bywartime restrictions. Starting in 1934, the Divisionhad brought the State registrars together in workconferences, to exchange viewpoints and unify regis-tration practices by cooperative agreements. Succes-sive conferences had been held in 1938, 1940, 1941,and 1942, when travel restrictions made large meet-ings impossible. As an interim device, the AmericanAssociation of Registration Executives in 1944 urgedthe Division to establish a representative Council, todeal with the many wartime problems. This new orga-nization, created the same year, consisted of sevenregional representatives elected by the registrationexecutives, the President and Secretary of the Regis-trars’ Association, and two Federal officials. From timeto time, the regional representatives called regionalmeetings. Despite the limitations of these stopgapmechanisms, they were invaluable in linking Stateand national registration and vital statistics interests.

Transfer to the Public HealthService: 1946

The Budget Bureau’s recommendations of 1943were adopted in July 1946, when the President’s Reor-ganization Plan No. 2 gave the Federal Security Admin-istrator25 authority for Federal functions in vital

25. Transferred to the Secretary of the Department of Health, Education, aWelfare, April 1953.

,ddr,

Appendix II 57

statistics. To administer these functions, and to pro-vide a single locus of authority for vital records at theFederal level, the National Office of Vital Statistics(NOVS) was established in the Public Health Service.

The National Office of Vital Statistics continued towork closely with the Council, which had proved souseful that it was continued even after the annualwork conference was resumed in 1947. Through thisannual conference and the Council, and in close coop-eration with the Registrars’ Association and the Sta-tistics Section of APHA, vital records and statisticsproblems of an interstate and national character werehandled with a fair degree of adequacy. But from apublic health viewpoint, there were still serious short-comings. Of paramount importance was the early devel-opment of a public health working conference andcommittee mechanism to unite the skills and experi-ence of all those producing public health statistics.This meant getting registration executives, vital stat-isticians, and public health statisticians, from all ofthe registration areas, into a conference-type organiza-tion that would function on a permanent basis.

This last essential was finally achieved on May 17,1949, when the Public Health Conference on Recordsand Statistics was formally launched. It was conceivedas a permanent organization, with working commit-tees assigned to specific problems, and an ExecutiveCommittee (Council) to conduct its affairs in the interimbetween national meetings. The Conference was essen-tially the culmination and fulfillment of organization

and work-methods that had been under developmentfor some time in the Council and the annual meetingof State registrars. But its scope was considerablybroadened beyond those of its two predecessors. Ofspecial importance was the broadening of its base toinclude the whole field of public health statistics inaddition to that of vital records and vital statistics.26

Ameasure of the remarkable progress made by theregistration system was provided by the second nation-wide test of birth registration completeness, whichwas made in conjuction with the 1950 census. This testindicated that 97.9 percent of the infants born in theearly part of that year had birth certificates on file invital statistics offices. In 24 States and the District ofColumbia, birth registration completeness was 99.0 per-cent or more and in only 7 States was it lower than95.0 percent. In the first nationwide test, made in1940, only 92.5 percent of the births had been regis-tered. Thus, the proportion of infants without birthcertificates was reduced almost three-quarters in the10-year period. A detailed discussion of the birth reg-istration tests appears in chapter 6.

26. The philosophy and working methods of the Public Health Conferenceand the impact of this coordinating mechanism on health records anstatistics, are described in ‘‘The Public Health Conference on Records anStatistics,’’ by Hazel V. Aune, Canadian Journal of Public Health, Decembe1951; and in ‘‘Records at Work,’’ published by the Public Health ConferenceMarch 1952.

Growth of the Birth- and Death-Registration Areas
The first birth and death statistics published by
the Federal Government concerned events in 1850 andwere for the entire United States. These statisticswere based on information collected during the decen-nial census of that year. Similar decennial collectionswere made by census enumerators at each census upto and including the census of 1900, but because of thetime interval between the occurrence of a birth or adeath and the census enumeration, these reports wereinaccurate and incomplete.

In 1880, the Bureau of the Census established anational ‘‘registration area’’ for deaths. This originalarea consisted of only two States—Massachusetts andNew Jersey—the District of Columbia, and severallarge cities having efficient systems for the registra-tion of deaths, but by 1900 eight other States had beenadmitted. For the years 1880, 1890, and 1900, mortal-ity data were received from the States and citiesincluded in this expanding area, but birth and deathfigures for the entire country were still compiled fromthe reports of census enumerators.

The annual collection of mortality statistics for theregistration area began with the calendar year 1900.

In 1902, the Bureau of the Census, which had previ-ously functioned only in census years, was made apermanent agency by an act of Congress. This actauthorized the Director of the Bureau of the Census toobtain, annually, copies of records filed in the vitalstatistics offices of those States and cities havingadequate death-registration systems. At that time notall States had enacted laws requiring the registrationof deaths, and in many States the existing laws werepoorly enforced. The important dates in the historicaldevelopment of birth and death registration in variousStates and the year in which each State was admittedto the national registration areas, are given intable 1.01.

The death-registration area for 1900 consisted of10 States, the District of Columbia, and a number ofcities located in nonregistration States. The registra-tion area in 1900 included 40.5 percent of the popula-tion of the continental United States. The originalregistration area was predominantly urban and char-acterized by a high proportion of white persons. Ifthose reporting cities located in nonregistration Statesare excluded, the population coverage of the death

Table 1.01. Important Dates in the History of Birthand Death Registration: United States

Area

Records on filefor entire area

Admitted toregistration area

Deaths Births Deaths Births

Alabama . . . . . . . . . . . . . . . . . . . . . . 1908 1908 1925 1927Arizona. . . . . . . . . . . . . . . . . . . . . . . . 1909 1909 1926 1926Arkansas. . . . . . . . . . . . . . . . . . . . . . 1914 1914 1927 1927California. . . . . . . . . . . . . . . . . . . . . . 1905 1905 1906 1919

Colorado . . . . . . . . . . . . . . . . . . . . . . 1907 1907 1906 1928Connecticut . . . . . . . . . . . . . . . . . . . 1897 1897 1890 1915Delaware. . . . . . . . . . . . . . . . . . . . . . 1881 1881 1890 1921District of Columbia . . . . . . . . . . . 1855 1871 1880 1915

Florida . . . . . . . . . . . . . . . . . . . . . . . . 1899 1899 1919 1924Georgia . . . . . . . . . . . . . . . . . . . . . . . 1919 1919 1922 1928Idaho. . . . . . . . . . . . . . . . . . . . . . . . . . 1911 1911 1922 1926Illinois . . . . . . . . . . . . . . . . . . . . . . . . . 1916 1916 1918 1922

Indiana . . . . . . . . . . . . . . . . . . . . . . . . 1900 1907 1900 1917Iowa. . . . . . . . . . . . . . . . . . . . . . . . . . . 1880 1880 1923 1924Kansas. . . . . . . . . . . . . . . . . . . . . . . . 1911 1911 1914 1917Kentucky . . . . . . . . . . . . . . . . . . . . . . 1911 1911 1911 1917

Louisiana. . . . . . . . . . . . . . . . . . . . . . 1914 1914 1918 1927Maine . . . . . . . . . . . . . . . . . . . . . . . . . 1892 1892 1900 1915Maryland . . . . . . . . . . . . . . . . . . . . . . 1898 1898 1906 1916Massachusetts . . . . . . . . . . . . . . . . 1841 1841 1880 1915

Michigan . . . . . . . . . . . . . . . . . . . . . . 1867 1867 1900 1915Minnesota. . . . . . . . . . . . . . . . . . . . . 1900 1900 1910 1915Mississippi . . . . . . . . . . . . . . . . . . . . 1912 1912 1919 1921Missouri . . . . . . . . . . . . . . . . . . . . . . . 1910 1910 1911 1927

Montana . . . . . . . . . . . . . . . . . . . . . . 1907 1907 1910 1922Nebraska. . . . . . . . . . . . . . . . . . . . . . 1905 1905 1920 1920Nevada . . . . . . . . . . . . . . . . . . . . . . . 1911 1911 1929 1929New Hampshire . . . . . . . . . . . . . . . 1850 1850 1890 1915

New Jersey . . . . . . . . . . . . . . . . . . . 1848 1848 1880 1921New Mexico. . . . . . . . . . . . . . . . . . . 1919 1919 1929 1929New York. . . . . . . . . . . . . . . . . . . . . . 1880 1880 1890 1915North Carolina . . . . . . . . . . . . . . . . 1913 1913 1910 1917

North Dakota. . . . . . . . . . . . . . . . . . 1908 1908 1924 1924Ohio. . . . . . . . . . . . . . . . . . . . . . . . . . . 1909 1909 1909 1917Oklahoma . . . . . . . . . . . . . . . . . . . . . 1908 1908 1928 1928Oregon. . . . . . . . . . . . . . . . . . . . . . . . 1903 1903 1918 1919

Pennsylvania. . . . . . . . . . . . . . . . . . 1906 1906 1906 1915Rhode Island. . . . . . . . . . . . . . . . . . 1852 1852 1890 1915South Carolina . . . . . . . . . . . . . . . . 1915 1915 1916 1919South Dakota . . . . . . . . . . . . . . . . . 1905 1905 1906 1932

Tennessee . . . . . . . . . . . . . . . . . . . . 1914 1914 1917 1927Texas . . . . . . . . . . . . . . . . . . . . . . . . . 1903 1903 1933 1933Utah. . . . . . . . . . . . . . . . . . . . . . . . . . . 1905 1905 1910 1917Vermont . . . . . . . . . . . . . . . . . . . . . . . 1857 1857 1890 1915

Virginia . . . . . . . . . . . . . . . . . . . . . . . . 1912 1912 1913 1917Washington . . . . . . . . . . . . . . . . . . . 1907 1907 1908 1917West Virginia. . . . . . . . . . . . . . . . . . 1917 1917 1925 1925Wisconsin . . . . . . . . . . . . . . . . . . . . . 1907 1907 1908 1917Wyoming . . . . . . . . . . . . . . . . . . . . . . 1909 1909 1922 1922

Alaska. . . . . . . . . . . . . . . . . . . . . . . . . 1913 1913 1950 1950Hawaii. . . . . . . . . . . . . . . . . . . . . . . . . 1896 1896 1917 1929Puerto Rico . . . . . . . . . . . . . . . . . . . 1931 1931 1932 1943Virgin Islands . . . . . . . . . . . . . . . . . 1919 1919 1924 1924

NOTE: See tables 1.03 and 1.04 for footnote references to several States.

Table 1.02. Growth of the Birth- and Death-RegistrationAreas: United States

(Beginning with 1933 and each succeeding year, areas include entirecontinental United States)

Year

Estimatedmidyearpopulation

of continentalUnitedStates

Birth-registrationStates

Death-registrationStates


Percentof total


Percentof total

1933 . . . . . . 125,578,763 125,578,763 100.0 125,578,763 100.01932 . . . . . . 124,840,471 118,903,899 95.2 118,903,899 95.21931 . . . . . . 124,039,648 117,455,229 94.7 118,148,987 95.3

1930 . . . . . . 123,076,741 116,544,946 94.7 117,238,278 95.31929 . . . . . . 121,769,939 115,317,450 94.7 115,317,450 94.71928 . . . . . . 120,501,115 113,636,160 94.3 113,636,160 94.31927 . . . . . . 119,038,062 104,320,830 87.6 107,084,532 90.01926 . . . . . . 117,399,225 90,400,590 77.0 103,822,683 88.4

1925 . . . . . . 115,831,963 88,294,564 76.2 102,031,555 88.11924 . . . . . . 114,113,463 87,000,295 76.2 99,318,098 87.01923 . . . . . . 111,949,945 81,072,123 72.4 96,788,197 86.51922 . . . . . . 110,054,778 79,560,746 72.3 92,702,901 84.21921 . . . . . . 108,541,489 70,807,090 65.2 87,814,447 80.9

1920 . . . . . . 106,466,420 63,597,307 59.7 86,079,263 80.91919 . . . . . . 104,512,110 61,212,076 58.6 83,157,982 79.61918 . . . . . . 103,202,801 55,153,782 53.4 79,008,412 76.61917 . . . . . . 103,265,913 55,197,952 53.5 70,234,775 68.01916 . . . . . . 101,965,984 32,944,013 32.3 66,971,177 65.7

1915 . . . . . . 100,549,013 31,096,697 30.9 61,894,847 61.61914 . . . . . . 99,117,567 - - - - - - 60,963,309 61.51913 . . . . . . 97,226,814 - - - - - - 58,156,740 59.81912 . . . . . . 95,331,300 - - - - - - 54,847,700 57.51911 . . . . . . 93,867,814 - - - - - - 53,929,644 57.5

1910 . . . . . . 92,406,536 - - - - - - 47,470,437 51.41909 . . . . . . 90,491,525 - - - - - - 44,223,513 48.91908 . . . . . . 88,708,976 - - - - - - 38,634,759 43.61907 . . . . . . 87,000,271 - - - - - - 34,552,837 39.71906 . . . . . . 85,436,556 - - - - - - 33,782,288 39.5

1905 . . . . . . 83,819,666 - - - - - - 21,767,980 26.01904 . . . . . . 82,164,974 - - - - - - 21,332,076 26.01903 . . . . . . 80,632,152 - - - - - - 20,943,222 26.01902 . . . . . . 79,160,196 - - - - - - 20,582,907 26.01901 . . . . . . 77,585,128 - - - - - - 20,237,453 26.1

1900 . . . . . . 76,094,134 - - - - - - 19,965,446 26.21890 . . . . . . 162,947,714 - - - - - - 19,659,440 31.21880 . . . . . . 150,155,783 - - - - - - 8,538,366 17.0

- - - Birth registration area was not established until 1915.1Population enumerated in the Federal census of May 31.

58 Appendix II

registration States is much lower, representing 26.2 per-cent of the total population of the United States.

Inasmuch as it is more difficult to obtain accurateand complete registration of births as compared withdeaths, the national birth-registration area was notestablished until 1915, and no birth statistics werepublished by the Bureau of the Census from 1900 to

1914. The original birth-registration area of 1915 con-sisted of 10 States and the District of Columbia. Thegrowth of this area is indicated in table 1.02.

Table 1.02 also presents for each year through1933 the estimated midyear population of the continen-tal United States and the estimated midyear popula-tion of those States included in the registration system.Beginning with 1933, the birth- and death-registrationareas have included all 48 States and the District ofColumbia. The year in which each State was admittedto the birth-registration area is shown in table 1.03,and to the death-registration area in table 1.04.

Prior to 1940, most of the national mortality tabu-lations published by the Bureau of the Census werebased on data collected from the registration areas,but beginning with 1940 all published material givenin statistical series for the United States prior to the

Table 1.03. Year in Which Each State was Admitted to theBirth-Registration Area

Year State Year State

1915 . . . . . . . . . . Connecticut 1921 . . . . . . . . . . DelawareMaine MississippiMassachusetts New JerseyMichigan 1922 . . . . . . . . . . IllinoisMinnesota MontanaNew Hampshire WyomingNew York 1924 . . . . . . . . . . FloridaPennsylvania IowaRhode Island1 North DakotaVermont 1925 . . . . . . . . . . West VirginiaDistrict of Columbia2 1926 . . . . . . . . . . Arizona

1916 . . . . . . . . . . Maryland Idaho1917 . . . . . . . . . . Indiana 1927 . . . . . . . . . . Alabama

Kansas ArkansasKentucky LouisianaNorth Carolina MissouriOhio TennesseeUtah 1928 . . . . . . . . . . ColoradoVirginia GeorgiaWashington OklahomaWisconsin 1929 . . . . . . . . . . Nevada

1919 . . . . . . . . . . California New MexicoOregon 1932 South DakotaSouth Carolina3 1933 . . . . . . . . . . Texas

1920 . . . . . . . . . . Nebraska

1Dropped from the birth-registration area in 1919; readmitted in 1921.2Included in States.3Dropped from the birth-registration area in 1925; readmitted in 1928.

Table 1.04. Year in Which Each State was Admitted tothe Death-Registration Area

Year State Year State

1880 . . . . . . . . . . Massachusetts 1911 . . . . . . . . . . MissouriNew Jersey 1913 . . . . . . . . . . VirginiaDistrict of Columbia1 1914 . . . . . . . . . . Kansas

1890 . . . . . . . . . . Connecticut 1916 . . . . . . . . . . South CarolinaDelaware2 1917 . . . . . . . . . . TennesseeNew Hampshire 1918 . . . . . . . . . . IllinoisNew York LouisianaRhode Island OregonVermont 1919 . . . . . . . . . . Florida

1900 . . . . . . . . . . Maine MississippiMichigan 1920 . . . . . . . . . . NebraskaIndiana 1922 . . . . . . . . . . Georgia5

1906 . . . . . . . . . . California IdahoColorado WyomingMaryland 1923 . . . . . . . . . . IowaPennsylvania 1924 . . . . . . . . . . North DakotaSouth Dakota3 1925 . . . . . . . . . . Alabama

1908 . . . . . . . . . . Washington West VirginiaWisconsin 1926 . . . . . . . . . . Arizona

1909 . . . . . . . . . . Ohio 1927 . . . . . . . . . . Arkansas1910 . . . . . . . . . . Minnesota 1928 . . . . . . . . . . Oklahoma

Montana 1929 . . . . . . . . . . NevadaNorth Carolina4 New MexicoUtah 1933 . . . . . . . . . . Texas

1911 . . . . . . . . . . Kentucky

1Included in States.2Dropped from the registration area in 1900; readmitted in 1919.3Dropped from the registration area in 1910; readmitted in 1930.4Included only municipalities with populations of 1,000 or more in 1900 (about 16 per-

cent of the total population); the remainder of the State was added to the area in 1916.5Dropped from the registration area in 1925; readmitted in 1928.

Appendix II 59

completion of the death-registration area in 1933 omitsdata for registration cities located in nonregistrationStates, and includes only findings for the registrationStates. This change decreases the mortality statisticscoverage of the United States by the exclusion of citiesin nonregistration States, but it has its advantages inthat more reliable population estimates are availablefor the registration States than for the registrationareas. No change in coverage has been made fornatality statistics since the birth-registration area atno time included cities in nonregistration States.

Because of the growth of the areas for which datahave been collected and tabulated, a national series ofgeographically comparable data prior to 1933 can beobtained only by estimation. Annual estimates of birthshave been prepared by P. K. Whelpton for the period1915 to 1934. (See table 6.02 in chapter 6.) Theseestimates include an adjustment for States not in thebirth-registration area prior to 1933 and for underreg-istration. In conjunction with annual estimates pre-

pared by the National Office of Vital Statistics for theperiod 1935 through 1949, they constitute a series ofdata consistent with respect to geographic coverageand registration completeness. Corresponding esti-mates for deaths are not yet available. However, ratesfor the expanding groups of death-registration Statesare approximations to complete national rates, andgeneral comparisons over a long period of years aremade. More exact trends for parts of the UnitedStates can be secured through the use of someconstant area, such as the original registration States,or the registration States of 1920. The crude mar-riage and divorce rates; birth rates; fetal deathratios; and death, infant mortality, and maternalmortality rates for the registration States, geo-graphic divisions, and individual States for a seriesof years are given in chapters 5, 6, 7, and 8. Rates orratios by place of occurrence and place of residenceare given in separate tables.

Marriages, Divorces, and Notifiable Diseases

Marriages and divorces

The earliest Federal statistics on marriages anddivorces in the United States were collected in a fieldsurvey by the Commissioner of Labor, covering the 20-yearperiod 1867 to 1886. A survey covering the next 20 years,and the single-year collections for 1916 and for each year

from 1922 to 1932 were made by the Bureau of theCensus. In all these studies, marriage statistics wereconfined to numbers of occurrences, by county, withconsiderable incompleteness for the first 20 years. Divorcedata were considered practically complete, and includeddetailed statistics on such items as legal grounds(‘‘causes’’), duration of marriage prior to divorce, etc.

see

l

Table 1.05. Sources of Marriage and Divorce Totals:United States, 1867–1950

Year Sources of marriage totals Sources of divorce totals1

1867–86 . . . . . . Estimates published in 1947by National Office of VitalStatistics, from incompletedata of survey by Comissionerof Labor, published in 1889.

Figures collected (withdetailed data) byCommissioner of Labor,published in 1889.

1887–1906 . . . . Estimates published in 1947by National Office of VitalStatistics, from data of nearlycomplete survey by Bureau ofthe Census, published in1908–1909.

Figures collected (withdetailed data) by Bureau ofthe Census, published in1908–1909.

1907–15 . . . . . . Estimates published in 1928by Bureau of the Census,from records of selectedStates.

(Same as marriage.)

1916 . . . . . . . . . . Figures collected by Bureauof the Census, published in1919.

Figures collected (withdetailed data) by Bureau ofthe Census, published in1919.

1917–21 . . . . . . Estimates published in 1928by Bureau of the Census,from the records of selectedStates.

(Same as marriage.)

1922–32 . . . . . . Figures collected each yearand published in annualreports by Bureau of theCensus.

Figures collected (withdetailed data) each year andpublished in annual reports byBureau of the Census.

1933–36 . . . . . . Estimates by S. A. Stoufferand L. M. Spencer (AmericanJournal of Sociology, January1939).

(Same as marriage.)

1937–40 . . . . . . Estimates published in 1942by Bureau of the Census,from nearly complete survey.

(Same as marriage.)

1941–43 . . . . . . Estimates published in 1946by National Office of VitalStatistics, from records ofselected States.

(Same as marriage.)

1944–50 . . . . . . Figures include estimates andmarriage licenses; publishedannually by National Office ofVital Statistics, from surveysof States and of selectedcounties.

Estimates published annuallyby National Office of VitalStatistics, from records ofselected States.

1Includes reported annulments.

Table 1.06. Year in Which the Central Filing of Marriageand Divorce Records Began

AreaMar-riage Divorce Area

Mar-riage Divorce

Alabama . . . . . . . . . . . . 1908 1908 New Hampshire . . . . . 1858 1881Arizona. . . . . . . . . . . . . . – – New Jersey . . . . . . . . . 1848 1795Arkansas. . . . . . . . . . . . 1917 1923 New Mexico. . . . . . . . . – –California. . . . . . . . . . . . 1905 – New York. . . . . . . . . . . . 1880 –

Colorado . . . . . . . . . . . . – – North Carolina . . . . . . – –Connecticut . . . . . . . . . 1897 1947 North Dakota. . . . . . . . 1925 1949Delaware. . . . . . . . . . . . 1913 1935 Ohio. . . . . . . . . . . . . . . . . 1949 1949Dist. of Columbia . . . 1811 1802 Oklahoma . . . . . . . . . . . – –

Florida . . . . . . . . . . . . . . 1927 1927 Oregon. . . . . . . . . . . . . . 1907 1925Georgia . . . . . . . . . . . . . – – Pennsylvania. . . . . . . . 1906 1943Idaho. . . . . . . . . . . . . . . . 1947 1947 Rhode Island. . . . . . . . 1852 –Illinois . . . . . . . . . . . . . . . – – South Carolina . . . . . . 1950 –

Indiana . . . . . . . . . . . . . . – – South Dakota . . . . . . . 1905 1905Iowa. . . . . . . . . . . . . . . . . 1880 1914 Tennessee . . . . . . . . . . 1945 1945Kansas. . . . . . . . . . . . . . 1913 – Texas . . . . . . . . . . . . . . . – –Kentucky . . . . . . . . . . . . – – Utah. . . . . . . . . . . . . . . . . 1919 –

Louisiana1. . . . . . . . . . . 1937 1942 Vermont . . . . . . . . . . . . . 1857 1896Maine . . . . . . . . . . . . . . . 1892 1892 Virginia . . . . . . . . . . . . . . 1853 1918Maryland . . . . . . . . . . . . 1914 1914 Washington . . . . . . . . . – –Massachusetts . . . . . . 1841 – West Virginia. . . . . . . . 1921 –

Michigan . . . . . . . . . . . . 1867 1897 Wisconsin . . . . . . . . . . . 1907 1907Minnesota. . . . . . . . . . . – – Wyoming . . . . . . . . . . . . 1941 1941Mississippi . . . . . . . . . . 1926 1926Missouri . . . . . . . . . . . . . 1948 1948 Alaska. . . . . . . . . . . . . . . 1913 1949

Hawaii. . . . . . . . . . . . . . . 1896 –Montana . . . . . . . . . . . . 1943 1943 Puerto Rico . . . . . . . . . 1931 1931Nebraska. . . . . . . . . . . . 1909 1909 Virgin Islands . . . . . . . – –Nevada . . . . . . . . . . . . . – –

– Not in registration area.1Not all parishes report.

60 Appendix II

In 1940, the Bureau of Census, through its VitalStatistics Division, undertook a new program of mar-riage and divorce statistics, following the pattern usedfor birth and death statistics. Transcripts of marriageand divorce records were collected, chiefly from thoseStates which could provide them through their Stateoffices of vital statistics. For the first time, the Federalprogram provided some detailed statistics on mar-riages, more than mere numbers of occurrences. How-ever, the data were for fewer than 30 States. Somedetailed statistics on divorces were obtained for 6 to 12States. Marriage data for 1939 and 1940 were pub-lished, as well as divorce data for 1939. This program

was discontinued, owing to war conditions. Mean-while, numbers or estimated numbers of occurrencesby State were obtained and published for the years1937 to 1940.

Beginning in 1944, the Bureau of the Census, atfirst through its Population Division and later throughits Vital Statistics Division, resumed efforts to providenumbers of occurrences. This program has been con-tinued by the former Vital Statistics Division, desig-nated the National Office of Vital Statistics since itstransfer to the Public Health Service in 1946.27 Inaddition, a program of detailed statistics of marriagesand divorces, based on State tabulations, was inaugu-rated by the National Office of Vital Statistics in 1949.Data for 1950 are presented in tables 1 through 12 inVolume II, as well as in several text tables in chapter 5.

Table 1.05 summarizes some of the preceding dis-cussion, and shows the sources of national marriageand divorce totals from 1867 to 1950.

27. For specific references to published reports of earlier surveys,‘‘Historical note on earlier studies’’ and footnotes in ‘‘Marriage and DivorceStatistics: United States, 1946,’’ National Office of Vital Statistics, VitaStatistics—Special Reports, vol. 27, No. 10, pp. 171, 172, 1947.

Appendix II 61

Table 1.06 shows for each State the year in whichcentral filing of marriage and divorce records wasstarted.

Notifiable diseasesThe collection of data on notifiable diseases by the

Public Health Service had its beginning nearly 75years ago when, by an act of Congress in 1878, suchcollection was authorized for use in connection withquarantine measures against such pestilential dis-eases as cholera, smallpox, plague, and yellow fever.One year later, a specific appropriation was made forthe collection and publication of reports of notifiablediseases, principally from foreign ports. In 1893, anact provided for the collection of information eachweek from State and municipal authorities throughout

the United States. In order to secure uniformity in theregistration of morbidity statistics, Congress enacted alaw in 1902, which directed the Surgeon General of thePublic Health Service to provide forms for the collec-tion, compilation, and publication of such data.

Reports on notifiable diseases were received from avery few States and cities prior to 1900, but graduallymore and more States submitted monthly and annualsummaries. It was not until after 1925 that all Statesreported regularly.

Until 1942, the collection, compilation, and publi-cation of morbidity statistics was under the directionof the Division of Sanitary Reports and Statistics ofthe Public Health Service. These functions were trans-ferred to the Division of Public Health Methods in1942, and to the National Office of Vital Statistics in1949.

62Appendix

II

Appendix II 63

The Vital Records and Statistics System
Records and statistics of vital events in the United
States flow from a coordinated system of separatelocal, State, and Federal agencies, as shown in theaccompanying chart. Legal responsibilities for the reg-istration and preservation of vital records are laidupon private citizens and upon officials at all levels ofgovernment. Responsibility for statistical services alsois laid by law upon agencies of government at all threelevels.

Nevertheless, the strength of the system lies in therecognition by all its participants of their commoninterests, and the ready cooperation that flows from

this understanding. Without it, the system would nothave attained its present degree of effectiveness. Thesuccess of the record programs and the value of thestatistics depend upon the precision and consistencywith which the many operations are performed. Whilethe law provides essential authorization for the sys-tem, only clear comprehension and the will to strivefor the common ends can give it success.

The remainder of this chapter describes briefly theorganization and functions of the vital records andstatistics system.

Registration and Reporting Activities
Vital records and reports originate with private
citizens—members of the families affected by the events,their physicians, funeral directors, clergymen, andothers. The responsibilities of these individuals aredefined in State laws, and penalties for noncomplianceare also provided by statute. The public’s understand-ing of the values of vital records is best evidenced bythe fact that State and local officials who administerthe State laws very seldom find it necessary to haleoffenders into the courts. The system draws millions ofreports from the population each year, while the enforce-ment cases are reckoned only in the dozens.

The following paragraphs describe the usual assign-ments of responsibility for furnishing facts on birth,death, fetal death, marriage, and divorce registrations.

Registration of birthsBy law, the registration of births is the direct

responsibility of the professional attendant at birth,generally a physician or midwife. In their absence, theparents of the child are responsible for the report.Each birth must be reported promptly—the reportingrequirements vary from State to State, ranging from24 hours after the birth to as much as 10 days.Certificates must be filed with the local registrar of thedistrict in which the birth occurs.

Registration of deathsBy law, the registration of deaths is the direct

responsibility of the funeral director, or person actingas such. The funeral director obtains the data requiredother than the cause of death. The person who sup-plies the information to the funeral director is usuallyrequired to sign the certificate as informant to attestto the truth of the facts entered. The physician inattendance at the death is required to indicate the

cause of death. If no physician was in attendance, thecoroner, or person acting as such, is required to enterthe cause of death. Where death is from other thannatural causes, the coroner may be required to exam-ine the body and report the cause of death, eventhough a physician was in attendance.

In most States, a burial-transit permit must beobtained from the local registrar of the district inwhich the death occurred, before the body may beremoved from the district, buried, or otherwise dis-posed of.

Registration of fetal deaths(stillbirths)

By law, the registration of fetal deaths (infantsborn dead) is the direct responsibility of the funeraldirector, or person acting as such. The funeral directorobtains the personal data required other than thecause of fetal death. The person who supplies the datato the funeral director is usually required to sign thecertificate as informant to attest to the truth of thefacts entered. Where a funeral director is not engaged,the physician is urged, in behalf of improved fetaldeath registration, to report the event to the localregistrar. The physician in attendance at the death isrequired to certify the cause of fetal death. If nophysician was in attendance, the coroner, or personacting as such, may be required to enter the cause offetal death. The coroner may be required to examinethe body and make the report where fetal death wascaused by other than natural cause.

A burial-transit permit must usually be obtainedfrom the local registrar of the district where the fetaldeath occurred, before the body may be removed fromthe district, cremated, or otherwise disposed of.

64 Appendix II

Registration of marriages anddivorces

In most States, marriage licenses are issued bytown or county clerks who obtain the personal particu-lars from the applicants and verify information fromthe serological tests. After the marriage is performed,the officiant (cleric or lay person) certifies to the factsof the marriage, and sends the record to the officialwho issued the license. In approximately three-fourthsof the States, there is now also some provision for the

local licensing official to send the original, a copy, or anabstract of the completed marriage record to the Stateregistrar of vital statistics. In most States, originaldivorce and annulment records are filed with the clerkor other official of the court where the decree isgranted. Personal particulars are obtained by the clerksfrom attorneys or petitioners. In approximately half ofthe States, there is now also some provision for filing acertificate or transcript abstracted from the recordwith the State registrar.

Vital Statistics Organization

In local areas

Each State is divided into local registration dis-tricts for the purpose of collecting vital records. Inmost cases, the extent of these districts is determinedby law. Originally, registration districts were verysmall, frequently consisting of each city, village, town,township, or road district. With increasing urbaniza-tion and improved transportation and communicationfacilities, districts have been consolidated in someStates so that now the entire county comprises thelocal registration district, while in others each city,incorporated town, or other primary political unit (suchas township or civil district) still constitutes the localregistration district. The number of registration dis-tricts was reduced from close to 30,000 in 1940 to lessthan 18,000 in 1950, and this trend still is in evidence.

A local registrar is appointed for each district and,where necessary, he is assisted by a deputy localregistrar. Local registrars may be appointed or mayacquire the duties of registrar in conjunction withlegal appointment to civil positions. In some States,the health officer of the county or large city is desig-nated as the local registrar, and the registration ofbirths, deaths, and fetal deaths becomes a regularfunction of the health department.

The local and county registrars are responsible forthe complete, accurate, and timely collection of vitalrecords. The Nation and the States rely on them forthe success of the system which can be no morereliable than are the basic data collected. These regis-trars are the officials who develop and maintain work-ing relationships with the physicians, midwives, funeraldirectors, coroners, and other persons required by lawto prepare and file vital records.

The duties of the local registrar generally includereceiving and collecting records of all births, deaths,and fetal deaths in his district; inspecting these certifi-cates for completeness and accuracy; querying, correct-ing, and completing the inconsistent or missing items;dating, signing, and numbering each record; issuingburial-transit permits; maintaining a local copy, regis-

ter, or index of the records; reporting infractions of theregistration law to county or State officials; promotingregistration reporting; and transmitting on a regularschedule, to the local health unit or to the Statedivision of vital statistics, all original certificatesreceived, except where duplicate copies are transmit-ted and the original records are retained in permanentfiles by the local offices. In some States, the localregistrar issues requested certified copies, for which afee is usually charged.

In some States, the office of the local registrar sendsnotifications of birth registration to new parents, to beretained if accurate or to be returned requesting correc-tion if inaccurate; the office may also be responsible forcarrying out the preliminary review and abstracting ofdelayed certificates of birth. In other States, both thenotification and delayed registration programs arehandled entirely by the State office.

For performance of the prescribed duties, the localregistrar usually is paid a fee by the county or Statefor each certificate filed.

The more recent development of transmitting thecertificates first to the county health unit and then onto the State office makes possible their use in currentplanning, development, and appraisal of the local healthprogram in the many States where this procedure is inpractice. For example, death certificates may be exam-ined to determine the causes of death and conditionsrelating thereto. Theymay be compared with case recordsto test the completeness of communicable disease report-ing. The birth certificates, and certificates for infant andmaternal deaths, indicate the need for and initiate vari-ous phases of the local infant and maternal hygieneprogram. Prompt and accurate information regardingbirths and deaths becomes in this way a daily tool in thework of an efficient local health organization.

Local registrars of vital statistics generally collectmarriage records only where, as in New England thetown clerks, or as in Illinois the county clerks, areresponsible for all nonjudicial records. Divorces andannulments, of course, are recorded in the courts thathear the suits.

Appendix II 65

In the States

The primary duties of the State vital records andstatistics office are the development and maintenanceof State and local procedures for the collection of vitalrecords, the enforcement of the law requiring that theevents be registered, and the production of State vitalstatistics.

Vital records are permanently filed in vital statis-tics divisions of the State governments. In NewEngland, with the exception of Rhode Island, originalrecords are maintained in the local offices; but in theseStates duplicate copies are maintained in State offices.In addition, a few large cities have been constituted byState law as independent registration areas whichmaintain files of their own original records.

Certificates from all parts of the State are receivedby the State office from the local registrars or countyhealth officers each month, on or before a date speci-fied by law. As a part of the process of receiving,completing, and filing them, the certificates are countedand verified against the number reported to have beensent. They are next examined for completeness, accu-racy, and timeliness, and are credited to the account ofthe appropriate local registrar. Monthly, quarterly,semiannually, or annually, depending upon State prac-tices, vouchers are prepared and transmitted either tothe State treasury or to the county commissioners orsupervisors who are obligated by law to pay the localregistrar. Special query forms or letters are sent to thelocal registrar or attendant asking for additional orclarifying information, if a certificate is deficient.

In nearly all States, some type of notification ofbirth form is sent to new parents by either the State orlocal registrar offices. About half of the State officesissue birth notification forms furnished by the NationalOffice of Vital Statistics. Others have developed theirown State forms, and in a number of areas the localoffice provides its own notification forms. Regardless ofthe form used or the office issuing it, the practice hasbeen found to be useful both in improving the accuracyof the information contained on the certificate and inimproving the completeness of birth registration. Expe-rience has demonstrated that many parents read thenotification carefully, and if names are misspelled, or ifthe date or the place of birth or other information isincorrect, the parents correct the notification form andreturn it for correction of the certificate.

Correction of vital records is one of the moreintricate tasks undertaken by State offices. Two dis-tinct points of view regarding the alteration and cor-rection of original certificates are reflected in differencesin the State procedures governing corrections. Accord-ing to one view, the principal value of the certificatelies in the fact that it is the original and that it hasremained unchanged throughout many years. Accord-ing to the other view, held by the majority, a certificate

should be accurate; and if through no fault of theindividual concerned there are errors in it, it should beamended upon the presentation of adequate evidence.In those States where the former point of view domi-nates, the registrar is forbidden, by statute or regula-tion, to make any alteration on the face of the certificatebut he is authorized to file and certify affidavits andother documents attesting to the inaccuracy of thefacts appearing on the face of the certificate. In Stateswhere the primary emphasis is on accuracy, the regis-trar may correct the face of the original certificateupon presentation of adequate documentary proof.

In all States, special consideration is given toadoption, legitimation, and foundling cases. Therecent tendency among the States has been to makelegislative provision for new birth certificates inthese instances. The law specifies that the originalcertificate in adoption cases shall be sealed with thecertified court order of adoption, while a new birthcertificate is prepared showing the adopting personsas the parents.

Central vital statistics offices issue certified copiesof birth and death certificates to qualified persons onrequest. In recent years, many States have developedforms by which official agencies may obtain confiden-tial verification of birth facts. Many States also use thebirth registration card or other type of short formcertification of birth facts which does not discloseinformation concerning birth out of wedlock, adoption,or medical data irrelevant to most certification pur-poses. A fee is usually charged for certifications andbirth cards and the vital statistics offices usuallymaintain fee accounting systems, although most Statesrequire that the revenues be paid into the State trea-sury. The number of certified copies issued by Stateoffices, although very large, is by no means a measureof the total volume of documents sought and obtainedby individuals and agencies as evidence of the factsconcerning births and deaths. Many county and munici-pal officers also issue copies of vital records whichwere filed with them prior to the establishment ofcentral registration or passed through their handsbefore reaching State offices.

The task of registering births which were notproperly registered within the time prescribed by law,has always been a part of the work of the State vitalstatistics office. (The development of uniform proce-dures and standards for filing delayed registrations ofbirth is referred to in the historical portion of the textin this chapter.) Applicants are required to submitdocumentary evidence sufficient to warrant the accep-tance for filing of a delayed certificate. As indicatedelsewhere, some of the local registrars are authorizedto conduct preliminary review activities for delayedregistration of births, for submittal to the State office.The State registrar is responsible for reviewing anddetermining whether the evidence presented to the

66 Appendix II

State or local offices is acceptable. In addition, in anumber of States delayed registrations may be filedthrough the local courts, Nebraska being the onlyState in which the courts are required by law toadhere to prescribed minimum standards of documen-tary evidence in accepting delayed registrations.

It is essential that certificates be located easilyand quickly, hence the value of an indexing system isapparent. In past years, typical State indexes con-sisted of handwritten or typed entries of the necessaryidentifying items for each certificate in ledgers or cardfiles. The present trend is to mechanical preparation ofindexes, although the States without tabulating equip-ment or those with a relatively small volume stillmaintain card indexes. Regardless of the type, theindexes are either alphabetic or phonetic and, in someStates, both systems are used. In the permanent files,the certificates usually are arranged by county andmonth of event, by surname, and in chronologicalorder. In most States they are bound, usually in booksof 500, either in sewed bindings or in some form of postor staple binder.

State offices furnish forms and supplies to localoffices as prescribed by law, sponsor training meetings,and provide instruction and advice for local registra-tion officials.

Table 1.06 indicates the year in which the variousState offices first provided for centralized registrationof marriages and divorces. Where such centralizedfiles are maintained, the State registrar receives theoriginal, a copy, or a partial transcript of the marriagerecord for marriages performed and some type oftranscript for each divorce granted. Offices havingcentral files of marriage and divorce records usuallymaintain indexes for both types of records and tabu-late and publish statistics in some degree of detail.

The procedures employed in processing statisticsvary in the different States, as do the resultant statis-tical services rendered. However, all States preparemonthly, quarterly, annually, or biennially, reports basedon data drawn from the various types of certificatesfiled. Thus, the information on the certificates is useddirectly in planning, evaluating, and administeringhealth activities.

The State vital statistics offices send copies (tran-scripts, microfilm, or punched tabulating cards) ofeach birth, death, and fetal death certificate to theNational Office of Vital Statistics of the U. S. PublicHealth Service.

In the United States

The Department of Health, Education, and Wel-fare is the Federal agency responsible for publishingnational vital statistics, and for giving expression tothe national interest in vital records. The Department

has entrusted the management of its program to thePublic Health Service, because that constituent agencyhas direct relations with the health agencies thatadminister vital records and vital statistics operationsin the States. The National Office of Vital Statistics isthe arm of the Public Health Service that conducts theFederal vital statistics program.

Publications of the National Office provide nationalstatistics of births, deaths, fetal deaths, marriages,divorces, and notifiable diseases. All of these are derivedfrom the routine registrations and reports collected byState and local governments. The data reach the Fed-eral agency through cooperative arrangements withthe States. The most detailed of the national reportsare those relating to deaths, while the simplest are thestatistics of notifiable diseases, which consist mainlyof counts of reported cases. At present, the NOVSobtains and publishes annual figures or estimates onnumbers of marriages and divorces occurring, togetherwith current monthly figures on numbers of marriagelicenses for the United States and divorces for a groupof States. In addition, beginning with data for 1948,some tables of detailed marriage and divorce statisticsare published, not for the entire United States, butonly for those States in which the State vital statisticsoffice is able to furnish such tables. The number ofStates able to supply these statistics and the amountof obtainable information have increased graduallyfrom year to year.

The National Office provides services needed tofoster more complete and uniform registration through-out the Nation. Among these services are: assistancein coordinating vital statistics activities of the variousState, city, and county health offices; promotion ofmore complete registration; the conduct of educationalcampaigns and tests for completeness of registration;assistance to State officials in developing standardforms, recommended legislation, standard definitions,and statistical tables; assistance to State agencies of aclearing-house nature; and development and promo-tion of methods for the collection and use of statisticaldata.

The National Office of Vital Statistics is the focalpoint of the vital records and statistics system. Itprovides the nerve center through which conflictingdemands upon the system are compromised by inter-state action of the responsible technicians. It providesa channel for clarification and resolution of problemsin Federal-State relations. It also is the country’srepresentative in the advancement of internationalcomparability in vital statistics, and the source towhich international agencies turn for United Statesdata.

For a list of reports published by the National Center for HealthStatistics contact:

Data Dissemination BranchNational Center for Health StatisticsCenters for Disease Control and Prevention6525 Belcrest Road, Room 1064Hyattsville, MD 20782(301) 436–8500Internet: http://www.cdc.gov/nchswww/nchshome.htm

http://www.cdc.gov/nchswww/nchshome.htm

DEPARTMENT OFHEALTH & HUMAN SERVICES

Centers for Disease Control and PreventionNational Center for Health Statistics6525 Belcrest RoadHyattsville, Maryland 20782

OFFICIAL BUSINESSPENALTY FOR PRIVATE USE, $300

DHHS Publication No. (PHS) 97-10036-0558 (2/97)

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PHS/NCHSPERMIT NO. G-281

Documents

U.S. Vital Statistics SystemOrganization of the Vital Statistics System" to 1950 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center