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Greetings to Our Partners in Care!

Welcome to this month's edition of GriefPerspectives!

Summer begins in 24 days and our state is opening in just a few more weeks. There is such a mix of excitement and anxiety, comfort and discomfort. We are all experiencing secondary losses in the wake of the pandemic - something I think our blog this week talked about very honestly and appropriately. 
 As we all look at each other in this strange new season of "return" I hope we can find the bravery we need to take these next steps and the compassion we need to be with others wherever they are in this transition.

An uplifting story:
A few weeks ago I received a phone call from a woman looking for resources and a support group for a non-death loss in her life. No one had died, she just knew we were serious about grief in all of its forms and here to help. I was so touched and SO proud of the work we are all doing to make grief-work accessible and de-stigmatized for so many. 
Your partner & resource,

Becky Lomaka, MA, CT
Director of Grief Support & Education
(949) 581-4300 ext. 229

The Value of a Death Certificate - to the Family and Society
by William G. Hoy

Referring to the newly-drafted United States Constitution, colonial statesman Benjamin Franklin (1907) wrote to Jean-Baptiste Leroy: “Our new Constitution is now established, and has an appearance that promises permanency; but in this world nothing can be said to be certain, except death and taxes”  (emphasis added) (p. 79). Everybody dies eventually so, at least in the developed world, everybody eventually has a death certificate with his or her name on it!



The death certificate is a legal document establishing the facts of an individual’s death and definitively identifying the deceased for legal purposes. The death certificate includes three main components: demographic and historical information identifying the deceased person, data certifying the supposed cause and manner of the death, and descriptions of the corpse’s disposition. In addition to legally establishing an individual’s death, the data can be combined with other deaths during a specific time period to discover patterns of disease for the purposes of prevention and treatment.
Most developed nations have elaborate death surveillance systems in place that depend on death certificate data; the United States, Canada, and the nations of western Europe have led the way in creating useable death registration systems. Mortality data is collected, tabulated, and reported by organizations such as Statistics Canada and the (U.S.) National Center for Health Statistics, a branch of the CDC. These data sets are extraordinarily important for tracking disease causes and courses as well as other significant health care trends. However, they depend almost entirely on the information gathered by the funeral director and added to by the attending physician or medical examiner to establish such trends.
Death certificates generally list the full legal name of the deceased, the date and place of birth, the usual address of the deceased, names and birthplaces of the deceased’s parents, and a government-issued identification number such as a Social Security number. Additionally, the death certificate includes demographic information such as the decedent’s race/nationality, marital status, employment, and education.
The underlying and immediate causes of death as well as death’s manner (natural, accident, suicide, or homicide) are determined by a physician, coroner, or medical examiner; almost always, the coroner/medical examiner is involved determining the causes and manner when a death is suspected or known to have been caused by accident, suicide, or homicide. A medical examiner often conducts a post-mortem examination (autopsy) to make this determination.
While there are often several notations on the death certificate related to death’s cause, the underlying cause is defined as the disease or injury that initiated the events resulting in death and would include such statements as motor vehicle accident, cancer of the stomach, or congestive heart failure. For the purposes of mortality surveillance, this is the most important cause; it is aggregated with all other deaths to establish mortality data such as 25% of U.S. deaths and about 20% of Canadian deaths are the result of heart disease. COVID-19 will almost certainly shift the numbers and percentages among the top causes of death but it will likely be 2022 or 2023 before we have final data. Preliminary analysis of the data would indicate that total deaths in the United States during 2020, for example, will have increased by about 250,000 or around 9% from the year before.
When death occurred under suspicious or unknown circumstances, the cause of death on the original certificate generally indicates that the death remains under investigation, listing the cause of death as “pending” or “deferred.” When drugs or alcohol are suspected to have contributed to the death, final determination of the cause must usually await the results of toxicology tests; in most jurisdictions, these analyses require at least two weeks to complete and often as long as six or seven weeks.
Some causes of death have multiple possible “manners” of death. For example, an opioid overdose could be the result of accident, suicide, or infrequently, homicide. In other words, the cause of death provides only the actual physiological mechanism of the death but it does not necessarily include the circumstances that caused that physiological mechanism to begin in the first place.
Funeral directors usually collect the personal data for the death certificate when initially meeting with families to talk about memorial arrangements. One advantage to pre-planning one’s funeral is that this data is already recorded by the “future deceased,” the person who likely knows this data best, saving family members from having to find information in the hours after a death. The kind of information that is often not known about older adults, for example, include such things as how long they have lived in the county or the names and birthplaces of the deceased’s own parents.
Certified copies of the death certificate are usually required to begin the process of settling or probating the deceased’s estate. After death, assets and liabilities in the deceased person’s name need to be transferred in an orderly fashion to other individuals or organizations in accordance with the deceased’s will, trust, or other estate plan. In order for family members to file claims for life insurance, Canada Pension, or Social Security, copies of the death certificate will certainly be required.
In addition to the need for death certification in establishing the facts of an individual’s death, the orderly collection of this data helps identify patterns of injury or disease in population groups. Links between environmental factors (such as type of employment) and disease are often spotted first in aggregated death certificate data. Because of the significant number of demographic factors reported, causes of death can be correlated with age, ethnicity, occupation, marital status, level of education, and geographical elements. While mistakes occur and not every death certificate accurately reports the deceased’s actual cause of death, epidemiologists believe the reporting is good enough to provide reliable population-level mortality data.
Enumerable examples illustrate how death certificate data is useful in research funding and policy development. The growth of HIV infection in the 1980s and the explosive opioid epidemic recently are two examples of how population-level data helps with identification and prevention activities.
Especially after a loved one died unexpectedly, individuals and families sometimes wait anxiously to see the cause of death on the death certificate; as explained above, they are often destined to wait many weeks before an official cause can be established. This uncertainty of the actual cause and circumstances, accompanied by questions of whether or not the deceased suffered, can greatly impact the course of early grief; not knowing the actual cause can prove even more difficult than knowing one’s loved one suffered significantly.
Clinicians and supportive professionals would serve their clients and patients well by inquiring what is known about the cause and circumstances of the death, whether the death certificate has been reviewed, and if not, an offer to review it with the patient. I have often found that the dread of knowing the facts is greater than learning the facts themselves and supportive professionals must be ready to help the bereaved negotiate this point.
Knowing death came from a specific cause often also fuels just the kind of motivation that lead to the establishment of foundations and organizations to promote mental health, to crusade against certain kinds of motor vehicle crashes, to provide advocacy for particular diseases, and to solicit contributions for research funds. Whether on a personal or social level, the death certification process is essential for much of the good that can be done in taking care of bereaved people.
Franklin, B. (1907). Smyth, Albert Henry (1907). The writings of Benjamin Franklin, Vol. X (1789-1790), edited by A. H. Smyth. New York, NY: MacMillian.
World Health Organization. (1979). Medical certification of cause of death. Geneva, Switzerland. WHO Publications. Retrieved from

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Our Events Calendar

Dr. Hoy is joining us August 3-5
for a series of Educational Workshops!

- More information to follow next month -
 Reiki + Meditation Circle

Give yourself this treat at the end of the week to start your weekend refreshed and relaxed.

Join Reiki Master and event host, Kathy Brook-Wong for our upcoming Zoom circles:
June 9th at 6:00pm - Register Here
July 28th at 6:00pm - Register Here

During this online Reiki + Peace with Grief Circle, Becky will share how grief is a universal human experience that does not require closure. Together we will explore ways to lean into grief, connecting ourselves to all of our feelings, discovering where we feel our grief in our bodies and how to practice positive self-care. Kathy will share about Reiki and how to use it to deepen your connection with Universal Life Force Energy. A distance Reiki healing will be gifted during our time together.
Advanced Registration is Required:
Click here to register.
After registering, you will receive a confirmation email containing information about joining us on Zoom.
Resource Review

COVID-19 Funeral Assistance
FEMA is reimbursing and/or covering the costs of funeral services rendered for anyone who died of COVID-19 or of COVID-related causes. The death certificate must have COVID listed to qualify (see how important they are?).

- Applicants for these funds must be U.S. citizens or legal residents and the person overseeing the financials of the funeral services. 
- Death must have occurred before January 20, 2020
- Death must have occurred in the United States
- Funds being distributed do NOT cover pre-paid funeral plans or insurance payouts

The COVID-19 Funeral Assistance is a free helpline provided over the phone (no computers or bots - you will speak with a person), with a single application. The average wait to speak with a representative is currently just 4 seconds. The application period opened on April 12th and at this time there is no deadline to file.

While assistance programs like these cannot undo any of the sorrow or horror of losing a loved one to COVID, there is the hope of showing support and compassion to the plurality of ways that death costs us. To have the financial burden of a death removed is a significant way to help.
Your Professional Library

Yalom, I. D. (2009). Staring at the Sun: Overcoming the Terror of Death. Jossey-Bass.

Reviewed by Molly A. Keating, MA, CT
Editor, GriefPerspectives

It's easy to dismiss a fear of death when we work in a profession that specializes in it. How could I be afraid of something I face every day? While Dr. Yalom does believe we vacillate through varying levels of fear and comfort with mortality - death anxiety is something none of us are immune to. In fact, it seems possible that many of us who witness it at such a high-rate of exposure may in-fact, be very, very afraid of our own deaths.

If you know death-anxiety is a factor for you or feel curious about exploring how we can "overcome the terror of death" - Staring at the Sun is the precise place to start. Irvin D. Yalom, MD is regarded as one of the great psychiatrists of our time. His writing intimately, calmly and masterfully walks us through the ancient musings on death and shows us the age of this primal fear. He speaks to the reader's fear with instinctual and sincere compassion. When we have our fears and truths acknowledged deeply and explained to us with so much compassion, the result is always great comfort. You will take that away from this book. Besides his topic being of great importance, the book is a page-turner full of wisdom and insight. 

Sharing from his experience of working with death-phobic patients, Yalom guides readers into a toleration of a truth we cannot extinguish, but must learn to live with. We know too well that we live the entire time we are actively dying - and we do everything we can to not see that dying/decay is often happening to us, around us, every single day. Yalom suggests acceptance and peace instead of aversion and denial. His tenure and authority in this area of study is itself a balm on the nagging fear and his wisdom in not solving the problem tells us he's on the right path.

To see more of his works, click here.

Research that Matters
Shapiro-Mendoza, C., Parks, S., Brustrom, J., Andrew, T., Camperlengo, L., Fudenberg, J., …Rhoda, D. (2017). Variations in cause-of-death determination for sudden unexpected infant deaths. Pediatrics, 140(1), e20170087. doi:10.1542/peds.2017-0087
Sudden unexpected infant deaths (SUIDS) are extraordinarily difficult to process for most parents, family members, and community friends. North American culture has largely turned a corner in infant and young child mortality so that children who leave the hospital healthy after delivery rarely die. When the unthinkable does occur, parents and caregivers need to understand what happened, whether they could have done anything to prevent the tragedy, and “what went wrong.” While making meaning of losses is a lifetime pursuit in grief, providing explanations to the cause of death can be meaningful to family members and to society at large if those findings can be translated into preventative strategies.
Expecting that coroners and medical examiners apply wildly different criteria and investigative procedures in establishing the cause of death of an otherwise-healthy infant, Shapiro-Mendoza and colleagues sought to understand how different medical examiners would rule on cause of death in three standardized death investigation scenarios. The researchers wrote, “Procedures routinely used to make a cause-of-death determination were highly consistent among survey respondents. It is encouraging that most ME/Cs reported using a combination of a death scene investigation, autopsy, and review of the medical record when making a cause-of-death determination for SUID, the 3 essential elements of a SUID investigation” (p. 5). The researchers also found that approximately 50% of the medical examiners/coroners completing the survey do not routinely use the term Sudden Infant Death Syndrome (SIDS) as a cause of death.

One concern about this last finding is that the actual incidence of SIDS could be underreported. While it was outside the scope of this project to investigate changes in the actual number of deaths from varied causes, the findings certainly raise the possibility that our common assumptions that SIDS deaths are declining in number could be based on flawed data. More research is needed to tease out the variables that could be at work in this finding in order to know how to appropriately conduct and fund research into varied causes of sudden unexpected infant death.
GriefPerspectives is published monthly by Grief Connect, Inc. Copyright ©2021. All rights reserved, including publication or distribution in any form, electronic or printed. For reprint permissions or suggestions for content, please email us at
Copyright © 2021 O'Connor Mortuary, All rights reserved.

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