The death certificate is an important source of data on disease incidence, prevalence and mortality. It should therefore be as accurate and complete as possible. Death certificates from 433 autopsied hospital patients were reviewed and matched against the results of post-mortem examinations. Significant discrepancies between the two documents were observed in 50% of patients. In 25%, the immediate cause of death was incorrectly stated on the certificate, having been assigned to a different organ system in the majority of those cases. In 33%, there was disagreement on major disease other than the immediate cause of death. In 9%, the death certificate was signed before the autopsy was performed. The extent of disagreement was largely independent of whether the certificate was signed before or after the autopsy. We conclude that: (1) there is a significant discrepancy between autopsy diagnoses and entries on death certificates; (2) disagreement is not due to unavailability of autopsy data at the time of completion of the certificate; (3) death certificates should be completed or amended utilizing data gained at autopsy.