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Appendices Appendices

Appendix C: Death during Travel

Francisco Alvarado-Ramy, Kendra E. Stauffer

Death of a friend, relative, or coworker can be immensely distressing. The situation is aggravated when death occurs abroad, where grieving people may be unfamiliar with local processes, language, and culture. Whether dealing with the death locally or from their home country, next of kin could face large, unanticipated costs, and labor-intensive administrative steps. Depending on the circumstances surrounding the dead, some countries may require an autopsy. Besides relatives, sources of support include the local consulate or embassy, travel insurance provider, tour operator, faith-based and aid organizations, and the deceased’s employer. There likely will need to be an official identification of the body. A body can be identified by witness statements of those who knew the person well, analyzing DNA samples, checking fingerprints, reviewing dental radiographs, or inspecting surgical implants.

DEATH ONBOARD A CONVEYANCE

The Federal Aviation Administration requires that flight attendants receive training in cardiopulmonary resuscitation (CPR) and in proper use of an automated external defibrillator (AED) at least once every 2 years. Under federal law, there are Good Samaritan protections for actions brought in a federal or state court resulting out of acts or omissions when people assist in a medical emergency during flight unless there is gross negligence or willful misconduct. If CPR is performed in the aircraft cabin, once it has been continued for 30 minutes or longer with no signs of life within this period, and no shocks advised by an AED, the person may be presumed dead and resuscitation efforts halted. Airlines may choose to specify additional criteria, depending upon the availability of ground-to-air medical consultation service or a physician aboard.

Cruise ships are usually better equipped than aircraft and carry medical professionals to provide clinical care. If the death occurs on a cruise ship despite medical interventions, the crew are usually able to provide logistic support to repatriate the body. Cruise ships are equipped with morgues and carry body bags.

US regulations require that all deaths aboard commercial flights and ships destined for the United States be reported to CDC.

OBTAINING DEPARTMENT OF STATE ASSISTANCE

When a US citizen dies outside the United States, the deceased person’s next of kin or legal representative should notify US consular officials at the Department of State. Consular personnel are available 24 hours a day, 7 days a week, to provide assistance to US citizens for overseas emergencies.

  • If the next of kin or legal representative is in the foreign country with the deceased US citizen, he or she should contact the nearest US embassy or consulate for assistance. Contact information for US embassies, consulates, and consular agencies overseas may be found at the Department of State website (www.usembassy.gov).
  • If a family member, domestic partner, or legal representative is in a different country from the deceased person, he or she should call the Department of State’s Office of Overseas Citizens Services in Washington, DC, from 8 am to 5 pm Eastern time, Monday through Friday, at 888-407-4747 (toll-free) or 202-501-4444. For emergency assistance after working hours or on weekends and holidays, call the Department of State switchboard at 202-647-4000 and ask to speak with the Overseas Citizens Services duty officer. In addition, the US embassy closest to or in the country where the US citizen died can provide assistance (www.usembassy.gov).

The Department of State has no funds to assist in the return of remains of US citizens who die abroad. US consular officers assist the next of kin by conveying instructions to the appropriate offices within the foreign country and providing information to the family on how to transmit the necessary private funds to cover the costs of preparing and repatriating human remains. The process can be expensive and lengthy. Upon issuance of a local (foreign) death certificate, the nearest US embassy or consulate may prepare a consular report of the death of an American abroad. Copies of that report are provided to the next of kin or legal representative and may be used in US courts to settle estate matters. If there is no next of kin or legal representative in-country, a consular officer will act as a provisional conservator of the deceased’s personal effects.

IMPORTATION OF HUMAN REMAINS FOR INTERMENT OR CREMATION

General Guidance

Except for cremated remains, human remains intended for interment (placement in a grave or tomb) or cremation after entry into the United States must be accompanied by a death certificate stating the cause of death. A death certificate is an official document signed by a coroner, health care provider, or other official authorized to make a declaration of cause of death. Death certificates written in a language other than English must be accompanied by an English translation. If a death certificate is not available in time for returning the remains, the US embassy or consulate should provide a consular mortuary certificate stating whether the person died from a disease classified as quarantinable in the United States (www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html). Any requirements of the country of origin, air carrier, US Customs and Border Protection, and the Transportation Security Administration must also be met (https://help.cbp.gov/app/answers/detail/a_id/237/~/requirements-for-importing-bodies-in-coffins-%2F-ashes-in-urns). CDC regulates the importation of human remains and provides guidance for their importation (www.cdc.gov/quarantine/human-remains.html). The requirements are more stringent if the person died from a disease classified as quarantinable in the United States.

EXPORTATION OF HUMAN REMAINS

CDC does not regulate the exportation of human remains outside the United States, although other state and local regulations may apply. The United States Postal Service is the only courier authorized to ship cremated remains. Exporters of human remains and travelers taking human remains out of the United States should be aware that the importation requirements of the destination country and the air carrier must be met. Information regarding these requirements may be obtained from the foreign embassy or consulate (www.state.gov/s/cpr/rls) and the air carrier.

BIBLIOGRAPHY

  1. Advisory circular: emergency medical equipment training. AC No. 121-34B. Washington, DC: Federal Aviation Administration, 2006. Available from: www.faa.gov/documentLibrary/media/Advisory_ Circular/AC121-34B.pdf.
  2. Bureau of Consular Affairs, US State Department. Death abroad. Washington, DC: US Department of State; 2014 [cited 2018 Feb 23]. Available from: https://travel.state.gov/content/passports/en/abroad/events-and-records/death.html.
  3. Bureau of Consular Affairs, US State Department. Return of remains of deceased US citizens. Washington, DC: US Department of State; 2014 [cited 2018 Feb 23]. Available from: https://travel.state.gov/content/travel/en/international-travel/while-abroad/death-abroad1/return-of-remains-of-deceased-us-citizen.html.
  4. CDC. Quarantine station contact list, map, and fact sheets. Atlanta: CDC; 2013 [cited 2018 Feb 23]. Available from: www.cdc.gov/quarantine/quarantinestationcontactlistfull.html.
  5. CDC. Guidance for importation of human remains into the United States for interment or subsequent cremation. Atlanta: CDC; 2014 [cited 2018 Feb 23]. Available from: www.cdc.gov/quarantine/human-remains.html.
  6. CDC. Specific laws and regulations governing the control of communicable diseases. Atlanta: CDC; 2014 [cited 2018 Feb 23]. Available from: www.cdc.gov/quarantine/specificlawsregulations.html.
  7. Connolly R, Prendiville R, Cusack D, Flaherty G. Repatriation of human remains following death in international travelers. J Travel Med. 2017 Mar 1;24(2):1–6.
  8. International Air Transport Association. Death on Board; 2016 [cited 2018 Feb 28]. Available from: www.iata.org/whatwedo/safety/health/Documents/death-on-board-guidelines.pdf.
  9. National Funeral Directors Association. Shipping remains from the United States to a foreign country. Brookfield, WI: National Funeral Directors Association; c2014 [cited 2018 Feb 23]. Available from: www.nfda.org/resources/operations-management/shipping-remains.
  10. U.S. Customs and Border Protection. Requirements for importing bodies in coffins/ashes in urns. Washington, DC: US Department of Homeland Security; 2015 [cited 2018 Feb 23]. Available from: https://help.cbp.gov/app/answers/detail/a_id/237/~/requirements-for-importing-bodies-in-coffins-%2F-ashes-in-urns.
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