South Africa has a well-established system for vital registration and collection of mortality statistics, but is challenged by under-reporting of death statistics, particularly in rural areas and of young children. (1) The quality of medical certification and misclassification of causes of death are also of concern. (2-5) Errors could result from difficulties in clinical diagnosis, poor certification or statistical coding and data processing. (6) Efforts have been made to improve cause of death information by standardising the reporting and coding of cause of death through the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). (7) This defines the underlying cause of death as the condition or injury that started the sequence of events leading directly to death and provides a standard format for medical certification on the death notification form (DNF). The DNF allows for four lines of information (labelled line a to line d in part I) on the causal sequence leading from the underlying cause to the immediate cause of death. The immediate cause should be listed in line a and the underlying cause on the lowest line. Contributory causes can also be listed in a second part (part II).