Let’s use this case study to complete the cause of death section on the DHA-1663 form. As mentioned earlier the cause of death section consists of two parts:

Part 1, with lines (a) to (d), which includes the causal sequence that directly caused the death, and 

Part 2, which contains any other significant conditions contributing to death, but are not part of causal sequence.

The causal sequence leading to death is entered in Part 1, with the immediate cause of death entered in line (a). This line must always be filled in. 

If the direct cause of death was a consequence of another disease or condition, this antecedent cause should be entered in Part 1 line (b).

If more than one line is completed, each condition must be a cause of the condition above it.  There must be a pathophysiological causal sequence. The initiating cause in the sequence is the underlying cause of death and should be reported on the lowest used line in Part 1.  Always use consecutive lines, starting at Part 1 line (a).  Never leave blank lines between filled in lines. If there is only one cause of death, it is entered at Part 1 line (a) and the subsequent lines are left blank. Enter only one disease, condition, event, or injury per line. 

Other significant conditions or risk factors that contributed to the death, but do not fit into the causal sequence, are entered in Part 2.  More than one condition can be entered on this line, but should be listed in order of importance.  Signs and symptoms and or modes of dying should not be reported in either Part 1 or Part 2.  The time interval between the onset of the condition and death is entered on the right of Part 1 and Part 2 to ensure that the causal sequence is in the correct order.  If the time interval is unknown, write “unknown”.  The duration of the underlying cause should be the longest. If more than 1 condition is entered in Part 2, insert the duration in brackets after each condition.