The certification of cause and manner of death is fundamental for legal and epidemiological purposes. In Italy, as in several other Euro- pean countries, the death certificate is legal proof of an individual’s death. The incorrect assessment of cause and manner of death can have serious implications for public health and the judicial system. Unnatural deaths can be erroneously reported as natural deaths, leav- ing accidents or homicides undetected. Many reasons can explain such inaccuracy, such as the level of training of medical practitioners involved in death investigations or a lack of information regarding the decedent’s medical history. In January of 2011, the Italian death certificate changed to conform to European rules dealing with statistical recording. This paper discusses the concept of manner of death in the Italian death investigation system, along with a brief history of Italian legislation, and discussion of the professionals involved in the certification of death, responsibilities for the determination of cause and manner, and how the manner of death is used.