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Died recently: 2021 or later (6 mo or older)

Do you know anyone who died in 2021 or later, age 6 months or older, where you know: 1. the date of last vaccination (if vaxxed), 2. the number of COVID shots (could be 0) 3. the date of death? You can guess at everything else, but those 3 things are critical. *** If you don't know them, pick another person. *** If you know these three things for multiple people, please choose the person whose details you are the MOST familiar with. All information, except as noted, will be made publicly available. If you are unsure of the correct answer to a question, just skip it. DO NOT GUESS. Thank you!

Your email for verification purposes only, not for publication
Full legal name is ideal. Will only be published if you consent. If you do not include at least the first and last name of the person who died, do not continue. Everything must be verifiable.
OK to publish name?
Do I have your permission to include the name of the person who died in the public survey data?
What was the age of the deceased? Round to the nearest year so a 6 month old would be 1.
Gender
Relationship
How do you know the person who died?
Cause(s) of death
Check all that apply to the primary cause of death
  • External forces (car accident, shooting, hurricane)
  • Self inflicted (suicide)
  • Drug overdose (fentanyl, ...)
  • Heart related: heart attack, cardiac arrest
  • Brain related: Stroke, bleeding in brain
  • Lung related
  • Clotting related: DVT, etc
  • Turbo cancer
  • Cancer
  • COVID
  • Other virus or infectious disease related
  • Organ failure
  • Multiple organ failure
  • Cause unknown; doctors not sure
Activity
What was the activity at the time of death? Leave blank if you do not know.
mm/dd/yyyy Example: 3/25/2021 IMPORTANT: Please be sure your date is on or after 1/1/2021 and it is in the format above. This is extremely important. You can type in the date. Hit tab when you are done.
Unexpected?
Was the death predictable? Or was it a surprise? By "predictable" I mean if I had asked you a week before the death whether you thought the person would be dead a week later, how would you answer?
Num COVID vaccines
How many COVID vaccines did the deceased receive? This is very important to be accurate here.
Country
What country did the person die in?
If you have a URL of a death notice, you can enter it here. Otherwise leave blank. Will only be made public if you agreed to make the name public.
If you were given a referral code, please enter it here.
Notes
Anything else you want me or the public to know? Also note here if there were any problems with the survey (something not clear or missing). Thanks! If you did not include a URL of the obituary notice, please explain why.
  • {name}

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