Seeing Death Up Close: Funeral Directors as Forgotten First Responders in the COVID-19 Pandemic

I am a New York and New Jersey licensed funeral director, one of the underrecognized “first responders” in the COVID-19 pandemic. As funeral directors, we normally interface with both the public health world of documenting vital statistics and the families and friends of the deceased. In public health, the funeral director is one of three required signatories for the certified death certificate, the others being the medical provider and the registrar in the municipality where the death occurred. We complete vital statistical information on the death record, the precursor to the death certificate. We are also tasked with ensuring correct wording of the cause of death (COD). As mandated reporters, we alert the local medical examiner’s office when the COD involves an injury, poisoning, or some manner other than “natural.” ¹

In February 2020, as deaths began to rise in New York and New Jersey, the local medical examiners’ offices were inundated because all suspected COVID-19 deaths were being reported to their office. Funeral directors, medical providers, and registrars were in the dark as to how to classify these deaths within the Electronic Death Registration System. Finally, in April 2020, the National Vital Statistics System provided guidance clearly stating that COVID-19 could not be reported as the immediate COD. Death certificates include three or four lines for COD. The immediate COD is the final disease or condition resulting in death; the remaining CODs are sequentially listed conditions with approximate interval to death onset. ²

This guidance led funeral directors, overwhelmed themselves with the numbers of deaths, to have to request already exhausted medical providers to change COVID-19 deaths on the Electronic Death Registration System as the immediate COD to another cause to prevent having the death certificate rejected by the registrar. At the same time, exhausted doctors protested that they did not have time to change the COD. If they did take it off, they would substitute a more generic natural cause. Families who came to funeral homes were expressing their own understandable traumas being unable to be with their loved ones at the time of their death. The COVID-19 alterations in how services were to be held were disruptive and traumatizing as well. Hospital morgues were filled to capacity with people who died of a strange and terrifying virus. Refrigeration trucks were quickly filled as soon as they were parked outside hospitals. ³ Cemeteries could not keep up with the demand. Some even closed temporarily. Local crematories were overwhelmed, requiring bodies to be transported hundreds of miles to other crematories. Countries were shutting down borders and not allowing repatriation of bodies for burial. ⁴ All religious houses closed for funeral gatherings and cemeteries were not allowing gatherings of groups in excess of very small numbers. For funeral directors, who are committed to our sacred responsibilities to the dead, their families, and to public safety, these events were especially difficult.

Making things more difficult, we had no guidance early in the pandemic from the Centers for Disease Control and Prevention or any public health agency as to the transmission risk of COVID-19 from the deceased. Most traditional funeral rites were suspended, such as embalming and Jewish and Muslim preparation of the dead. ⁵ Thankfully, as officers of the Metropolitan Funeral Directors Association—the trade organization that serves our industry in New York City—I and my fellow officers were in constant contact with the New York City Office of Medical Examiners and with the New York State Funeral Directors Association. They were an enormous help in working with politicians to address the needs of funeral directors. Eventually the National Guard was sent in to help transport the dead to temporary holding areas until licensed funeral directors could attend to them. Other funeral directors from around the country were given temporary legal authority in New York and New Jersey to assist us. ⁶

We also sought the wisdom of more weathered colleagues with experience in the AIDS epidemic to deal with social concerns and biohazard threats. The stigma of AIDS had led families to request changes in the COD for privacy reasons. But doctors were mandated at the time to report it. The contentiousness of this issue resulted in the New York City death certificate not listing any type of COD; it only states “natural causes.” (New York City has its own death registration system apart from New York State.) We were seeing the same happening with COVID-19. Though a death certificate in New York City could list “natural causes,” death certificates in New Jersey and New York State specified COVID-19 sequentially as a contributory cause. But families would sometimes request that COVID-19 not appear anywhere on the death certificate. Previous AIDS experiences also underscored the need for barrier precautions for funeral directors and their staff until transmission risk could be determined. Our trade associations helped procure supplies of personal protective equipment and face masks for those running dangerously low during those early months.

Starting April 12, 2021, the Federal Emergency Management Agency began offering COVID-19 funeral assistance—up to $9000 in compensation—to families for funeral services. Yet, many doctors, in their frustration with the National Vital Statistics System, did not list COVID-19 on the death certificate. Furthermore, those families who did not want COVID-19 listed on the death certificate might now wish otherwise. Funeral directors are fielding daily phone calls from families who want help amending the COD. Undoubtedly, we will never truly know the real COVID-19 death toll of 2020. So many people died scared and alone in hospitals that were desperately overburdened. So many families were torn apart by such sudden, unexpected deaths. We funeral directors were and still are the last loving human touch for these people. Like other first responders, we carry deeply the traumas of this pandemic.