Primary Tumor Page 1 of 5
Primary Tumor
Study ID __________________________________
Patient details
* Gender Male
Female
* DOB __________________________________
(YYYY-MM-DD)
Diagnosis details
* Diagnosis Chordoma
Chondrosarcoma Osteosarcoma Ewing's sarcoma
Other malignant bone tumor
Malignant peripheral nerve sheath tumor Other malignant soft tissue tumor Giant cell tumor
Osteoid osteoma Osteoblastoma Hemangioma Osteochondroma Aneurysmal bone cyst
Langerhans cell histiocytosis (LCH) (eosinophilic) Giant vertebral notochordal rest
Other benign bone tumor Schwannoma
Other benign soft tissue tumor Unknown
If unknown, please provide a reason __________________________________
If "Other" diagnosis, specify __________________________________
* How Diagnosis Obtained Open Biopsy
CT-trocar Biopsy Intra-operative Biopsy Other
Unknown
If other, please specify __________________________________
If unknown, please provide a reason __________________________________
Is a Date of Biopsy Procedure known? Yes
No
Not Applicable
If Yes, please specify Date of Biopsy Procedure __________________________________
(YYYY-MM-DD) Please provide a valid date
* Previous Spine Tumor Operation? Yes
No Unknown
Page 2 of 5
If unknown, please provide a reason __________________________________
Type of previous spine tumor operation Intralesional Marginal Wide Unknown
Is a Date of Onset of Symptoms known? Yes
No
Not Applicable
Date of Onset of Symptoms __________________________________
(YYYY-MM-DD) Please provide a valid date
Pain at Diagnosis? Yes
No Unknown
Pathologic Fracture at Diagnosis? Yes
No Unknown
Neurologic Status NOTE: Frankel OR ASIA should be listed below, as recorded in the medical record.
Both are not necessary.
Neurologic Status: Frankel Score A
B C D E
Unknown
Neurologic Status: ASIA Score A
B C D E
Unknown
Neurologic Status: Myelopathy? Yes
No Unknown
Neurologic Status: Cauda Equina? Yes
No Unknown
* Age (in years) at Diagnosis __________________________________
(years)
If unknown, please provide a reason __________________________________
Page 3 of 5
Tumor Description (if tumor confined to 1 level, list that level as BOTH upper and lower level)
* Upper Spinal Level C1
C2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4 S5 Coccyx Unknown
If unknown, please provide a reason __________________________________
Page 4 of 5
* Lower Spinal Level C1
C2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4 S5 Coccyx Unknown
If unknown, please provide a reason __________________________________
* Enneking Classification I a
I b II a II b III a III b S1 S2 S3 Unknown Not Applicable
If unknown, please provide a reason __________________________________
WBB WBB sectors
[Inline Image: "WBB_new1.jpg"]
Page 5 of 5
WBB Sectors (report range counterclockwise based on 1
image above) 2
3 4 5 6 7 8 9 10 11 12 Unknown Not Applicable
WBB Sectors 1
2 3 4 5 6 7 8 9 10 11 12 Unknown Not Applicable
WBB tissue layers A
B C D E F
Unknown Not Applicable
WBB tissue layers A
B C D E F
Unknown Not Applicable
Primary Tumor Page 1 of 3
Surgery
Study ID __________________________________
Pre-op Embolization? Yes
No Unknown
Surgery date and duration
* Date of Surgery __________________________________
(YYYY-MM-DD) Please provide a valid date
OR Time (minutes) __________________________________
(minutes)
Surgical Approach Anterior
Posterior
Anterior/Posterior Posterior/Anterior
Anterior/Posterior/Anterior Posterior/Anterior/Posterior Other
Unknown If Staged is a 2nd procedure date known? Yes
No
Not Applicable
2nd procedure date __________________________________
(YYYY-MM-DD) Please provide a valid date
OR Time (minutes) __________________________________
(minutes) If Staged is a 3rd procedure date known? Yes
No
Not Applicable
3rd procedure date __________________________________
(YYYY-MM-DD) Please provide a valid date
OR Time (minutes) __________________________________
(minutes) If Staged is a 4th procedure date known? Yes
No
Not Applicable
If Staged, 4th procedure date __________________________________
(YYYY-MM-DD) Please provide a valid date
OR Time (minutes) __________________________________
(minutes)
Page 2 of 3
Tumor details
* Size of Tumor A/P (cm) (based on pathological __________________________________
examination) (cm)
If unknown, please provide a reason __________________________________
* Size of Tumor L/R (cm) (based on pathological __________________________________
examination) (cm)
If unknown, please provide a reason __________________________________
* Size of Tumor C/C (cm) (based on pathological __________________________________
examination) (cm)
If unknown, please provide a reason __________________________________
Tumor Volume (cc) __________________________________
(cc)
If unknown, please provide a reason __________________________________
Surgeon's Assessment
Surgeon's Pre-op Surgical Plan Palliative (limited decompression/stabilization without oncologic intent)
Intralesional subtotal Intralesional gross total
En bloc: wide with focal intralesional transgression
En bloc: wide with marginal margin En bloc: wide with wide margin Unknown
Surgeon's Post-op Assessment of Type of Surgery Palliative (limited decompression/stabilization without oncologic intent)
Intralesional subtotal Intralesional gross total
En bloc: wide with focal intralesional transgression
En bloc: wide with marginal margin En bloc: wide with wide margin Unknown
Surgery details
* Pathology results from the surgical specimen Intralesional Marginal Wide Unknown
If unknown, please provide a reason __________________________________
* Procedure at Spine Intralesional
Marginal Wide Unknown
If unknown, please provide a reason __________________________________
Page 3 of 3
* Procedure at Dura Intralesional
Marginal Wide Unknown
If unknown, please provide a reason __________________________________
* Fixation used Anterior
Posterior Both None Unknown
If unknown, please provide a reason __________________________________
Reconstruction (vertebral replacement) Autograft Allograft Titanium cage Carbon fiber cage Vascular autograft Cement
None Unknown
Neurology Sacrificed
Cord Yes
No Unknown
Cauda Equina Yes
No Unknown
Nerve Roots Yes
No Unknown
If Yes, list the Nerve Roots sacrificed __________________________________
Primary Tumor Page 1 of 11
Complications
Study ID __________________________________
Early Complications (intraoperative or acute peri-operative)
Early Complication 1 Airway/Ventilation
Allergic reaction Anesthesia related
Bone implant interface failure requiring revision Cardiac
Cord injury Dural tear
Hardware malposition requiring revision Hypotension (systemic < 85mm Hg for 15 min) Massive blood loss (>5L in 24 hrs or >2L in 3 hrs) Nerve root injury
Neurological Deterioration Pressure sores
Vascular injury Visceral injury Other
Unknown
((If there are no early complications, leave blank))
If Other early complication, specify __________________________________
Was reoperation of the spine required for early Yes
complication? No
Unknown
Is a Date of Reoperation known? Yes
No
Date of Reoperation __________________________________
(YYYY-MM-DD) Please provide a valid date
Early Complication 2 Airway/Ventilation
Allergic reaction Anesthesia related
Bone implant interface failure requiring revision Cardiac
Cord injury Dural tear
Hardware malposition requiring revision Hypotension (systemic < 85mm Hg for 15 min) Massive blood loss (>5L in 24 hrs or >2L in 3 hrs) Nerve root injury
Neurological Deterioration Pressure sores
Vascular injury Visceral injury Other
Unknown
((If there are no early complications, leave blank))
If Other early complication, specify __________________________________
Page 2 of 11
Was reoperation of the spine required for early Yes
complication? No
Unknown
Is a Date of Reoperation known? Yes
No
Date of Reoperation __________________________________
(YYYY-MM-DD) Please provide a valid date
Early Complication 3 Airway/Ventilation
Allergic reaction Anesthesia related
Bone implant interface failure requiring revision Cardiac
Cord injury Dural tear
Hardware malposition requiring revision Hypotension (systemic < 85mm Hg for 15 min) Massive blood loss (>5L in 24 hrs or >2L in 3 hrs) Nerve root injury
Neurological Deterioration Pressure sores
Vascular injury Visceral injury Other
Unknown
((If there are no early complications, leave blank))
If Other early complication, specify __________________________________
Was reoperation of the spine required for early Yes
complication? No
Unknown
Is a Date of Reoperation known? Yes
No
Date of Reoperation __________________________________
(YYYY-MM-DD) Please provide a valid date
Early Complication 4 Airway/Ventilation
Allergic reaction Anesthesia related
Bone implant interface failure requiring revision Cardiac
Cord injury Dural tear
Hardware malposition requiring revision Hypotension (systemic < 85mm Hg for 15 min) Massive blood loss (>5L in 24 hrs or >2L in 3 hrs) Nerve root injury
Neurological Deterioration Pressure sores
Vascular injury Visceral injury Other
Unknown
((If there are no early complications, leave blank))
If Other early complication, specify __________________________________
Page 3 of 11
Was reoperation of the spine required for early Yes
complication? No
Unknown
Is a Date of Reoperation known? Yes
No
Date of Reoperation __________________________________
(YYYY-MM-DD) Please provide a valid date
Early Complication 5 Airway/Ventilation
Allergic reaction Anesthesia related
Bone implant interface failure requiring revision Cardiac
Cord injury Dural tear
Hardware malposition requiring revision Hypotension (systemic < 85mm Hg for 15 min) Massive blood loss (>5L in 24 hrs or >2L in 3 hrs) Nerve root injury
Neurological Deterioration Pressure sores
Vascular injury Visceral injury Other
Unknown
((If there are no early complications, leave blank))
If Other early complication, specify __________________________________
Was reoperation of the spine required for early Yes
complication? No
Unknown
Is a Date of Reoperation known? Yes
No
Date of Reoperation __________________________________
(YYYY-MM-DD) Please provide a valid date
Early Complication 6 Airway/Ventilation
Allergic reaction Anesthesia related
Bone implant interface failure requiring revision Cardiac
Cord injury Dural tear
Hardware malposition requiring revision Hypotension (systemic < 85mm Hg for 15 min) Massive blood loss (>5L in 24 hrs or >2L in 3 hrs) Nerve root injury
Neurological Deterioration Pressure sores
Vascular injury Visceral injury Other
Unknown
((If there are no early complications, leave blank))
If Other early complication, specify __________________________________
Page 4 of 11
Was reoperation of the spine required for early Yes
complication? No
Unknown
Is a Date of Reoperation known? Yes
No
Date of Reoperation __________________________________
(YYYY-MM-DD) Please provide a valid date
Early Complication 7 Airway/Ventilation
Allergic reaction Anesthesia related
Bone implant interface failure requiring revision Cardiac
Cord injury Dural tear
Hardware malposition requiring revision Hypotension (systemic < 85mm Hg for 15 min) Massive blood loss (>5L in 24 hrs or >2L in 3 hrs) Nerve root injury
Neurological Deterioration Pressure sores
Vascular injury Visceral injury Other
Unknown
((If there are no early complications, leave blank))
If Other early complication, specify __________________________________
Was reoperation of the spine required for early Yes
complication? No
Unknown
Is a Date of Reoperation known? Yes
No
Date of Reoperation __________________________________
(YYYY-MM-DD) Please provide a valid date
Early Complication 8 Airway/Ventilation
Allergic reaction Anesthesia related
Bone implant interface failure requiring revision Cardiac
Cord injury Dural tear
Hardware malposition requiring revision Hypotension (systemic < 85mm Hg for 15 min) Massive blood loss (>5L in 24 hrs or >2L in 3 hrs) Nerve root injury
Neurological Deterioration Pressure sores
Vascular injury Visceral injury Other
Unknown
((If there are no early complications, leave blank))
If Other early complication, specify __________________________________
Page 5 of 11
Was reoperation of the spine required for early Yes
complication? No
Unknown
Is a Date of Reoperation known? Yes
No
Date of Reoperation __________________________________
(YYYY-MM-DD) Please provide a valid date
Early Complication 9 Airway/Ventilation
Allergic reaction Anesthesia related
Bone implant interface failure requiring revision Cardiac
Cord injury Dural tear
Hardware malposition requiring revision Hypotension (systemic < 85mm Hg for 15 min) Massive blood loss (>5L in 24 hrs or >2L in 3 hrs) Nerve root injury
Neurological Deterioration Pressure sores
Vascular injury Visceral injury Other
Unknown
((If there are no early complications, leave blank))
If Other early complication, specify __________________________________
Was reoperation of the spine required for early Yes
complication? No
Unknown
Is a Date of Reoperation known? Yes
No
Date of Reoperation __________________________________
(YYYY-MM-DD) Please provide a valid date
Early Complication 10 Airway/Ventilation
Allergic reaction Anesthesia related
Bone implant interface failure requiring revision Cardiac
Cord injury Dural tear
Hardware malposition requiring revision Hypotension (systemic < 85mm Hg for 15 min) Massive blood loss (>5L in 24 hrs or >2L in 3 hrs) Nerve root injury
Neurological Deterioration Pressure sores
Vascular injury Visceral injury Other
Unknown
((If there are no early complications, leave blank))
If Other early complication, specify __________________________________
Page 6 of 11
Was reoperation of the spine required for early Yes
complication? No
Unknown
Is a Date of Reoperation known? Yes
No
If Yes, Date of Reoperation __________________________________
(YYYY-MM-DD) Please provide a valid date
Late Complications (post-operative)
Late Complication 1 Cardiac arrest/failure/arrhythmia
Construct failure with loss of correction Construct failure without loss of correction CSF leak/meningocele
Deep vein thrombosis Deep wound infection Delirium
Dysphagia Dysphonia GI bleeding Hematoma
Myocardial infarction
Neurologic deterioration >1 motor grade in ASIA motor scale
Non-union Pneumonia
Postoperative neuropathic pain Pressure sores
Pulmonary embolism Superficial wound infection Systemic infection
Urinary tract infection Wound dehiscence Other
Unknown
((If there are no late complications, leave blank))
If Other late complication, specify late complication __________________________________
1
Page 7 of 11
Late Complication 2 Cardiac arrest/failure/arrhythmia
Construct failure with loss of correction Construct failure without loss of correction CSF leak/meningocele
Deep vein thrombosis Deep wound infection Delirium
Dysphagia Dysphonia GI bleeding Hematoma
Myocardial infarction
Neurologic deterioration >1 motor grade in ASIA motor scale
Non-union Pneumonia
Postoperative neuropathic pain Pressure sores
Pulmonary embolism Superficial wound infection Systemic infection
Urinary tract infection Wound dehiscence Other
Unknown
((If there are no late complications, leave blank))
If Other late complication, specify late complication __________________________________
2
Late Complication 3 Cardiac arrest/failure/arrhythmia
Construct failure with loss of correction Construct failure without loss of correction CSF leak/meningocele
Deep vein thrombosis Deep wound infection Delirium
Dysphagia Dysphonia GI bleeding Hematoma
Myocardial infarction
Neurologic deterioration >1 motor grade in ASIA motor scale
Non-union Pneumonia
Postoperative neuropathic pain Pressure sores
Pulmonary embolism Superficial wound infection Systemic infection
Urinary tract infection Wound dehiscence Other
Unknown
((If there are no late complications, leave blank))
If Other late complication, specify late complication __________________________________
3
Page 8 of 11
Late Complication 4 Cardiac arrest/failure/arrhythmia
Construct failure with loss of correction Construct failure without loss of correction CSF leak/meningocele
Deep vein thrombosis Deep wound infection Delirium
Dysphagia Dysphonia GI bleeding Hematoma
Myocardial infarction
Neurologic deterioration >1 motor grade in ASIA motor scale
Non-union Pneumonia
Postoperative neuropathic pain Pressure sores
Pulmonary embolism Superficial wound infection Systemic infection
Urinary tract infection Wound dehiscence Other
Unknown
((If there are no late complications, leave blank))
If Other late complication, specify late complication __________________________________
4
Late Complication 5 Cardiac arrest/failure/arrhythmia
Construct failure with loss of correction Construct failure without loss of correction CSF leak/meningocele
Deep vein thrombosis Deep wound infection Delirium
Dysphagia Dysphonia GI bleeding Hematoma
Myocardial infarction
Neurologic deterioration >1 motor grade in ASIA motor scale
Non-union Pneumonia
Postoperative neuropathic pain Pressure sores
Pulmonary embolism Superficial wound infection Systemic infection
Urinary tract infection Wound dehiscence Other
Unknown
((If there are no late complications, leave blank))
If Other late complication, specify late complication __________________________________
5
Page 9 of 11
Late Complication 6 Cardiac arrest/failure/arrhythmia
Construct failure with loss of correction Construct failure without loss of correction CSF leak/meningocele
Deep vein thrombosis Deep wound infection Delirium
Dysphagia Dysphonia GI bleeding Hematoma
Myocardial infarction
Neurologic deterioration >1 motor grade in ASIA motor scale
Non-union Pneumonia
Postoperative neuropathic pain Pressure sores
Pulmonary embolism Superficial wound infection Systemic infection
Urinary tract infection Wound dehiscence Other
Unknown
((If there are no late complications, leave blank))
If Other late complication, specify late complication __________________________________
6
Late Complication 7 Cardiac arrest/failure/arrhythmia
Construct failure with loss of correction Construct failure without loss of correction CSF leak/meningocele
Deep vein thrombosis Deep wound infection Delirium
Dysphagia Dysphonia GI bleeding Hematoma
Myocardial infarction
Neurologic deterioration >1 motor grade in ASIA motor scale
Non-union Pneumonia
Postoperative neuropathic pain Pressure sores
Pulmonary embolism Superficial wound infection Systemic infection
Urinary tract infection Wound dehiscence Other
Unknown
((If there are no late complications, leave blank))
If Other late complication, specify late complication __________________________________
7
Page 10 of 11
Late Complication 8 Cardiac arrest/failure/arrhythmia
Construct failure with loss of correction Construct failure without loss of correction CSF leak/meningocele
Deep vein thrombosis Deep wound infection Delirium
Dysphagia Dysphonia GI bleeding Hematoma
Myocardial infarction
Neurologic deterioration >1 motor grade in ASIA motor scale
Non-union Pneumonia
Postoperative neuropathic pain Pressure sores
Pulmonary embolism Superficial wound infection Systemic infection
Urinary tract infection Wound dehiscence Other
Unknown
((If there are no late complications, leave blank))
If Other late complication, specify late complication __________________________________
8
Late Complication 9 Cardiac arrest/failure/arrhythmia
Construct failure with loss of correction Construct failure without loss of correction CSF leak/meningocele
Deep vein thrombosis Deep wound infection Delirium
Dysphagia Dysphonia GI bleeding Hematoma
Myocardial infarction
Neurologic deterioration >1 motor grade in ASIA motor scale
Non-union Pneumonia
Postoperative neuropathic pain Pressure sores
Pulmonary embolism Superficial wound infection Systemic infection
Urinary tract infection Wound dehiscence Other
Unknown
((If there are no late complications, leave blank))
If Other late complication, specify late complication __________________________________
9
Page 11 of 11
Late Complication 10 Cardiac arrest/failure/arrhythmia
Construct failure with loss of correction Construct failure without loss of correction CSF leak/meningocele
Deep vein thrombosis Deep wound infection Delirium
Dysphagia Dysphonia GI bleeding Hematoma
Myocardial infarction
Neurologic deterioration >1 motor grade in ASIA motor scale
Non-union Pneumonia
Postoperative neuropathic pain Pressure sores
Pulmonary embolism Superficial wound infection Systemic infection
Urinary tract infection Wound dehiscence Other
Unknown
((If there are no late complications, leave blank))
If Other late complication, specify late complication __________________________________
10
Primary Tumor Page 1 of 2
Treatment
Study ID __________________________________
Is Estimated Blood Loss known? Yes
No
Estimated Blood Loss (mL) __________________________________
(mL) Is total transfusion of blood through hospital stay Yes
known? No
Total transfusion of blood through hospital stay units of PRBC
measured in mL
Amount __________________________________
Amount __________________________________
Is a Length of Hospital Stay known? Yes
No
Length of Hospital Stay (days) __________________________________
(days)
Chemotherapy
* What was the timing of chemotherapy? Pre-op Post-op Both
Neither (no chemo) Time unknown
If unknown, please provide a reason __________________________________
If chemo was given, is a date when it was initiated Yes
known? No
If Yes, please specify a date __________________________________
(YYYY-MM-DD) Please provide a valid date
If chemo was given, were there any drugs administered? Yes No
Please list drugs (and specify whether pre-op, __________________________________
post-op, both, or unknown)
Radiation
* What was the timing of radiation therapy? Pre-op Post-op Both
Neither (no radiation) Time unknown
If unknown, please provide a reason __________________________________
Page 2 of 2
Is a date when radiation therapy was given known? Yes No
If Yes, please specify a date __________________________________
(YYYY-MM-DD) Please provide a valid date
If radiation therapy was given, type of radiation Conventional
therapy 3D
IMRT
Radiosurgery Proton beam Unknown
Primary Tumor Page 1 of 3
Recurrence
Study ID __________________________________
Local Recurrence 1
* Local Recurrence 1 Yes
No Unknown
If unknown, please provide a reason __________________________________
Is Local Recurrence 1 Date known? Yes
No
Local Recurrence 1 Date __________________________________
(YYYY-MM-DD) Please provide a valid date
Local Recurrence 1 Treatment __________________________________
Local Recurrence 2
Local Recurrence 2 Yes
No Unknown
Is Local Recurrence 2 Date known? Yes
No
Local Recurrence 2 Date __________________________________
(YYYY-MM-DD) Please provide a valid date
Local Recurrence 2 Treatment __________________________________
Local Recurrence 3
Local Recurrence 3 Yes
No Unknown
Is Local Recurrence 3 Date known? Yes
No
Local Recurrence 3 Date __________________________________
(YYYY-MM-DD) Please provide a valid date
Local Recurrence 3 Treatment __________________________________
Page 2 of 3
Local Recurrence 4
Local Recurrence 4 Yes
No Unknown
Is Local Recurrence 4 Date known? Yes
No
Local Recurrence 4 Date __________________________________
(YYYY-MM-DD) Please provide a valid date
Local Recurrence 4 Treatment __________________________________
Local Recurrence 5
Local Recurrence 5 Yes
No Unknown
Is Local Recurrence 5 Date known? Yes
No
Local Recurrence 5 Date __________________________________
(YYYY-MM-DD) Please provide a valid date
Local Recurrence 5 Treatment __________________________________
Local Recurrence 6
Local Recurrence 6 Yes
No Unknown
Is Local Recurrence 6 Date known? Yes
No
Local Recurrence 6 Date __________________________________
(YYYY-MM-DD) Please provide a valid date
Local Recurrence 6 Treatment __________________________________
Local Recurrence 7
Local Recurrence 7 Yes
No Unknown
Is Local Recurrence 7 Date known? Yes
No
Local Recurrence 7 Date __________________________________
(YYYY-MM-DD)
Page 3 of 3
Please provide a valid date
Local Recurrence 7 Treatment __________________________________
Local Recurrence 8
Local Recurrence 8 Yes
No Unknown
Is Local Recurrence 8 Date known? Yes
No
Local Recurrence 8 Date __________________________________
(YYYY-MM-DD) Please provide a valid date
Local Recurrence 8 Treatment __________________________________
Primary Tumor Page 1 of 2
Status
Study ID __________________________________
Last follow up
* Date of Last Clinical Follow-up __________________________________
(YYYY-MM-DD) Please provide a valid date
* Status as of last clinical follow-up Alive with no evidence of local or systemic disease Alive with evidence of local disease but no
systemic disease
Alive with evidence of systemic disease but no local disease
Alive with evidence of systemic and local disease Died from disease without evidence of local disease at time of death
Died from disease with evidence of local disease at time of death
Died of unrelated cause without evidence of local or systemic disease at time of death
Died of unrelated cause with evidence of local but no evidence of systemic involvement at time of death
Died of unrelated cause with evidence of systemic but no evidence of local involvement at time of death
Died of unrelated cause with evidence of local or systemic disease at time of death
Unknown
Date of today __________________________________
(YYYY-MM-DD) Please provide a valid date
Days since clinical follow up __________________________________
Current Vital Status
* Date of contact / information __________________________________
(YYYY-MM-DD) Please provide a valid date
If unknown, please provide a reason __________________________________
* Source of information Official vital data statistics
Family doctor Medical charts Patient him/herself Relatives etc.
Unknown
If unknown, please provide a reason __________________________________
* Current Vital status Dead
Alive Unknown
Page 2 of 2
* If Deceased, Date of Death __________________________________
(YYYY-MM-DD) Please provide a valid date
If Deceased, is the cause of death known? Known Unknown
If Deceased, cause of death __________________________________
