Citation Nr: 0204946 Decision Date: 05/23/02 Archive Date: 06/03/02 DOCKET NO. 96-38 857 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: Jeany Mark, Attorney WITNESSES AT HEARING ON APPEAL Appellant and her son ATTORNEY FOR THE BOARD N. W. Fabian, Counsel INTRODUCTION The veteran had active duty from November 1945 to December 1965. This matter comes to the Board of Veterans' Appeals (Board) from an April 1996 rating decision of the Department of Veterans Affairs (VA) Denver, Colorado, Regional Office (RO), in which the RO denied entitlement to service connection for the cause of the veteran's death. The appellant, the veteran's surviving spouse, perfected an appeal of that decision. This case was previously before the Board in February 1998, at which time the Board remanded the case to the RO for additional development. Following the completion of that development the RO returned the case to the Board, and in a June 2000 decision the Board denied entitlement to service connection for the cause of the veteran's death. The appellant appealed that decision to the United States Court of Appeals for Veterans Claims (Court) and, based on a Joint Motion for Remand, in a December 2000 order the Court vacated the Board's June 2000 decision and remanded the case to the Board for consideration of the Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000) (VCAA), and re-adjudication. FINDINGS OF FACT 1. The RO has notified the appellant of the evidence needed to substantiate her claim; obtained any relevant, available evidence designated by the appellant; and obtained a VA medical opinion in order to assist her in substantiating her claim for VA benefits. 2. The veteran died in January 1992 due to sepsis. 3. Sepsis was not shown during service and is not shown to be related to an in-service disease or injury or a service- connected disorder. 4. At the time of the veteran's death service connection had not been established for any disorder. 5. A disorder that was incurred in service did not cause or substantially or materially contribute to cause the veteran's death. CONCLUSION OF LAW The cause of the veteran's death was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 1310, 5107 (West 1991 and Supp. 2001); 38 C.F.R. §§ 3.5, 3.303, 3.310, 3.312 (2001). (continued on next page) REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background The veteran's service medical records indicate that in April 1964 he complained of pain in the chest, which after examination was found to probably not be due to cardiac disease. His blood pressure was then 150 millimeters (mm)/100 mm, and the treating physician noted that the veteran was very anxious. In December 1964 the veteran was given a limited profile for effusion in the left knee, and diagnostic testing was then negative for gout or arthritis. He was treated for pain in the low back and hips on multiple occasions during service, which was variously assessed as the result of a fatty tumor, lumbosacral strain, and in July 1965 as rheumatoid spondylitis or rheumatoid arthritis of the left sacroiliac joint. On separation from service in September 1965 the veteran reported having or having had swollen or painful joints; pain or pressure in the chest; cramps in his legs; arthritis or rheumatism; bone, joint, or other deformity; and foot trouble. He also stated that he was unable to bend due to back pains, and that he could not lay flat without leg or hip pain. In commenting on those complaints the examining physician made reference to a lipoma on the right shoulder. Physical examination revealed no relevant abnormalities, other than the lipoma on the right shoulder, and the veteran's blood pressure was then 118 mm/82 mm. The service medical records are otherwise silent for any relevant complaints or clinical findings, including testing for or a diagnosis of hypertension. The veteran did not apply for VA compensation benefits during his lifetime, and service connection had not been established for any disorder at the time of his death. Treatment records from the Walter Reed Army Medical Center (Walter Reed) show that the veteran was hospitalized in September 1986, on transfer from Providence Hospital, for evaluation of hypertension and the new onset of diabetes mellitus. The diabetes mellitus was detected after admission to Providence Hospital, at which time the veteran had reported symptoms lasting for the previous week. He had not seen an internist for at least five years, and stopped using his blood pressure medication eight months previously. His past medical history was significant for degenerative joint disease in both knees, hypertension of five years in duration, and cardiomegaly by chest X-ray for more than 10 years. He later reported having had hypertension for 20 years. His medication for hypertension was again given, which brought his blood pressure within the range of normal. He was also given insulin for the control of diabetes. The death summary covering the veteran's final hospitalization at Walter Reed indicates that he was admitted to that facility in December 1991 on transfer from the D.C. General Hospital due to having had a right thalamic stroke. On admission the physician noted that the veteran had a history of hypertension, insulin-dependent diabetes mellitus, renal insufficiency, peptic ulcer disease, a prior cerebrovascular accident in November 1990, anemia, a seizure disorder, and gouty arthritis. Four days prior to admission he experienced the acute onset of a right-sided headache, weakness, diaphoresis, diplopia, and left-sided paralysis. A computerized tomography (CT) scan conducted at D.C. General Hospital had shown a large thalamic hemorrhagic stroke with blood in the third and fourth ventricles. On admission to Walter Reed the veteran was lucid, alert, and in no acute distress, although unable to move his left side. His blood pressure was then 198 mm/ 102 mm. He later developed a fever, mild mental status changes, apneic episodes, and markedly increased hypertension, which the attending physician assessed as sepsis, and antibiotics were initiated. He was also treated for gout in the right knee and elbow. He developed symptoms consistent with sepsis syndrome, and mechanical ventilation was applied. The use of antibiotics continued, but no source of the fever or sepsis could be determined. He later developed nosocomial pneumonia associated with the mechanical ventilation. He remained febrile and had progressive renal and liver dysfunction, and the attending physician found that his course was consistent with a progressive septic syndrome without clear etiology. A CT scan of the sinuses showed pansinusitis, which persisted and a sphenoid drainage was performed. The veteran had declining mental status and evidence of multiple organ failure and the mechanical ventilation was discontinued. He expired shortly thereafter. According to the death summary, the diagnoses at death consisted of septic syndrome, pansinusitis, fungal colonization of the bladder, right thalamic hemorrhagic stroke, hypertension, gouty arthritis, insulin-dependent diabetes mellitus, multi-organ system failure with renal and hepatic insufficiency, a history of peptic ulcer disease, and follicular dermatitis. The original death certificate shows that the veteran died in January 1992, with the immediate cause of death being sepsis. The death certificate was signed by the physician who attended the veteran during his final hospitalization. In July 1995 the appellant asked Walter Reed to amend the death certificate on the basis that the veteran had manifested a heart attack, [hypertension], stroke, gout, and several other illnesses during service and after his retirement from active duty. She asserted that the death certificate did not clearly state the series of illnesses leading up to his death, which was needed in order for her to obtain the government benefits she sought. In August 1995 the staff of Casualty/Mortuary Affairs at Walter Reed asked the registrar of vital statistics to amend the death certificate to indicate that the immediate cause of death was sepsis, right thalamic stroke; due to or a consequence of pulmonary congestion and hypostasis; due to or a consequence of hypertensive renal disease; due to or a consequence of gouty arthropathy. Other significant conditions contributing to death but not related to the underlying cause consisted of diabetes mellitus and renal insufficiency. The registrar of vital statistics then certified that the requested changes had been made to the death certificate. The letter from the staff of Casualty/Mortuary Affairs to the appellant indicates that the changes were made to the death certificate because those disorders were reflected in the veteran's medical chart during his last admission to Walter Reed. In her August 1996 substantive appeal the appellant asserted that the veteran's hypertension had its onset during service, and that hypertension substantially contributed to cause his death. She and her son provided testimony before the undersigned in November 1997, at which time her son stated that the veteran had been treated for a blood disorder and pulmonary problems during service. He also asserted that the disorders treated during service were related to the disorders that caused the veteran's death. He stated that the veteran was noted to have diabetes in 1948, and that he was found to have gout while in service. The appellant testified that the veteran received treatment at Fort Carson, Colorado, from 1965 to 1972, and at Walter Reed from 1972 until his death. She stated that hypertension was diagnosed while the veteran was in service, and that he first had hypertension in 1955. She described this "hypertension" as the veteran holding his head, and receiving medication. She also stated that the veteran was given blood pressure medication just before he retired from service, and in making that statement she referenced April and December 1964 service medical records. She further stated that there were times that the veteran could not walk due to musculoskeletal problems, and that he was often limited to quarters due to those problems. She testified that he had syphilis in service that was not treated, and asserted that the syphilis had stayed in his blood stream and contributed to his death. As a result of the Board's February 1998 remand, the RO requested a medical opinion from a VA physician regarding the relationship, if any, between the disorders documented during service and the cause of the veteran's death. In a January 2000 report John E. Hill, M.D., who is board-certified in internal medicine and cardiology, summarized the data pertaining to the veteran's death in January 1992, as documented in the death summary from Walter Reed, and found that the veteran died of sepsis, not the stroke that had precipitated his hospitalization. He noted that on entering the hospital the veteran was stable and in no acute distress, and that his recovery was anticipated had it not been for the onset of sepsis. He stated that the stroke was not related to the ultimate cause of death, but that sepsis was the overwhelming cause. He found that the diabetes, renal insufficiency, and gouty arthritis had no significant contribution to the veteran's final illness and death, in that they were not related to the sepsis. Dr. Hill noted the report of the September 1986 hospitalization at Walter Reed, showing the new onset of diabetes mellitus and that the veteran had had hypertension for 20 years. He also summarized the service medical records, noting the various blood pressure readings, multiple negative chest X-rays, and the treatment of syphilis and multiple musculoskeletal disorders. He found significant the notation in April 1964 that the veteran was "very anxious" at the only time in service that he had an elevated blood pressure reading. Dr. Hill stated, following a review of the entire claims file, that there was no evidence of the veteran having hypertension or diabetes while in service. He also found no clear evidence of the veteran having had gouty arthritis while in service, although the joint fluid in the left knee may or may not have been related to gouty arthritis. There was only one reference to pulmonary congestion, that being in April 1964, and Dr. Hill found that had the April 1964 symptoms been caused by chronic cardiovascular disease, the disease would have been manifested by progressive symptomatology from that point. He found no evidence of hypertensive renal disease prior to 1965. He also found that there was no relationship between terminal sepsis, pulmonary congestion, hypostasis, hypertensive renal disease, gouty arthropathy, diabetes mellitus, or renal insufficiency and any disease or injury shown before December 1965. Following the December 2000 remand by the Court, the appellant's representative submitted a medical opinion from Craig N. Bash, M.D., a neuroradiologist, in support of the appellant's claim. In an October 2001 report Dr. Bash stated that he had reviewed the claims file and found that the veteran had hypertension during service, that the first symptoms of gouty arthritis and spine disease occurred during service, and that the veteran died from a combination of sepsis and a stroke. He also stated that, in his opinion, the service-related gouty arthritis and back disorder had made it impossible for the veteran to exercise, thereby increasing his risk for cardiovascular disease and contributing to cause his death. He found that the hypertension was related to service, that the stroke was secondary to hypertension, and that the stroke was responsible for the veteran developing sepsis because otherwise he would not have been hospitalized. In explaining those opinions Dr. Bash referenced specific findings regarding the veteran's musculoskeletal complaints documented in the service medical records, the elevated blood pressure reading in April 1964, the death summary, and the death certificate. He disagreed with Dr. Hill's assertion that hypertension was not shown during service, by referencing the single blood pressure reading of 150 mm/100 mm in April 1964. He cited to medical texts showing that a diastolic blood pressure reading of 90-104 mm represented mild hypertension, and that long-standing hypertension was a well known cause of cardiovascular disease. He stated that the fact that subsequent blood pressure readings, a chest X-ray, and an electrocardiogram (EKG) were normal did not refute the onset of hypertension, because the disease could be asymptomatic for 15-20 years and because X-ray and EKG changes often "lagged behind" the blood pressure changes. He also found that a single, normal blood pressure reading in 1965 was not sufficient to rule out hypertensive disease, in that multiple readings should be taken over multiple days to rule out hypertension. Dr. Bash also found that the evidence of non-traumatic effusion in the knees was evidence of the onset of gouty arthritis in service, and that Dr. Hill's assessment that the effusion may or may not represent gout had to be interpreted as a finding that it was gout. He also found that the effusion had to be considered gout, because no other explanation for the finding had been given. Dr. Bash stated that the stroke resulting in the December 1991 hospitalization was caused by hypertension, that the veteran would not have developed sepsis but for the hospitalization, that his musculoskeletal complaints prevented him from exercising, and that the hypertension and gouty arthritis had, therefore, contributed to his death. In support of that assertion he cited a medical text that pertained to the increased incidence of hypertension and ischemic heart disease in persons with spinal cord injuries and amputees. He then noted that Dr. Hill had not referred to any medical texts in support of his opinion. Duty to Assist The regulation pertaining to VA's duty to inform the appellant of the evidence needed to substantiate her claim and to assist her in developing the relevant evidence was revised subsequent to the initiation of her claim. Duty to Assist, 66 Fed. Reg. 45,620 (Aug. 29, 2001) (to be codified at 38 C.F.R. § 3.159). The changes in the regulation are effective November 9, 2000, with the enactment of the VCAA, and apply to all claims filed on or after November 9, 2000, or filed previously but not yet final as of that date. Holliday v. Principi, 14 Vet. App. 282-83 (2001), mot. for recons. denied, 14 Vet. App. 327 (2001) (per curiam), motion for review en banc denied, No. 99-1788 (U.S. Vet. App. May 24, 2001) (per curiam) (en banc); VAOPGCPREC 11-2000. Because the appellant appealed the April 1996 denial of service connection that decision did not become final, and the provisions of the VCAA apply to her claim. According to the revised regulation, on receipt of a claim for benefits VA will notify the appellant of the evidence that is necessary to substantiate the claim. VA will also inform the appellant which information and evidence, if any, that she is to provide and which information and evidence, if any, VA will attempt to obtain on her behalf. VA will also ask the appellant to provide any evidence in her possession that pertains to the claim. VA will also make reasonable efforts to help the appellant obtain evidence necessary to substantiate the claim, including making efforts to obtain service medical records, if relevant to the claim; other relevant records pertaining to service; VA medical records; and any other relevant records held by any Federal department or agency, State or local government, private medical care provider, current or former employer, or other non-Federal governmental source. Duty to Assist, 66 Fed. Reg. 45,630 (Aug. 29, 2001) (to be codified at 38 C.F.R. § 3.159). The RO informed the appellant of the evidence needed to substantiate her claim in September 1995, February 1996, and May 1998. The RO provided the appellant a statement of the case and supplemental statements of the case in August 1996, January 1997, and January 2000. In those documents the RO informed the appellant of the regulatory requirements for establishing service connection, and provided her the rationale for not awarding service connection. In the February 1998 remand the Board informed the appellant of the need to submit all medical treatment records since the veteran's separation from service, and the need to obtain a medical opinion showing a relationship between a disability incurred in service and the cause of death. The appellant was asked during the November 1997 hearing to identify all medical care providers who treated the veteran since his separation from service. The RO notified the appellant each time her case was sent to the Board, and informed her that any additional evidence that she had should be submitted to the Board. The appellant's representative was notified when the Court remanded the case to the Board, and was asked to submit additional evidence and argument in support of the appellant's appeal. She then submitted the medical opinion from Dr. Bash. The Board finds, therefore, that VA has fulfilled its obligation to inform the appellant of the evidence needed to substantiate her claim. The RO has obtained the veteran's service medical records, and the available service department treatment records. The Board notes that during the November 1997 hearing the appellant testified that the veteran had received treatment from the service department medical facility at Fort Carson, Colorado, from 1965 to 1972, and from Walter Reed from 1972 until his death in 1992. In February 1996, however, the appellant had requested all of the veteran's treatment records from Walter Reed, and the only records found pertained to the hospitalization in September 1986 and his final hospitalization. As a result of the Board's February 1998 remand the appellant was asked to identify all medical care providers who treated the veteran since his separation from service, and she then stated that he had received treatment at Georgetown University Hospital and Fort Carson. The RO requested the treatment records from Georgetown University Hospital, and notified the appellant of that request and the need to submit those records, but none were provided. The RO also requested from the National Personnel Records Center (NPRC) all of the records documenting the veteran's treatment at Fort Carson, but none were located. The RO obtained a medical opinion to assist the appellant in substantiating her claim, and her representative provided a medical opinion in response to that of Dr. Hill. The appellant and her son presented hearing testimony before the undersigned in November 1997. She has not indicated the existence of any other evidence that is relevant to her appeal. The Board concludes that all relevant data has been obtained for determining the merits of the appellant's claim and that, given the development that has been undertaken in this case, no reasonable possibility exists that any further assistance would aid the appellant in substantiating the claim. Wensch v. Principi, 15 Vet. App. 362, 368 (2001). Laws and Regulations Dependency and Indemnity Compensation (DIC) benefits are payable to the surviving spouse of a veteran if the veteran died from a service-connected disability. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.5. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110, 1131. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303. Service connection may also be granted for a disability which is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). Where a veteran served for 90 days in active service, and a cardiovascular disorder, including hypertension, develops to a degree of 10 percent or more within one year from the date of separation from service, such disease may be service connected even though there is no evidence of such disease in service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In order to establish service connection for the cause of the veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. The issue involved will be determined by the exercise of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the veteran. 38 C.F.R. § 3.312(a). In order to constitute the principal cause of death the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. In order to be a contributory cause of death, it must be shown that the service-connected disability contributed substantially or materially to cause death; that it combined to cause death; or that it aided or lent assistance to the production of death. It is not sufficient to show that the service-connected disorder casually shared in producing death, but rather it must be shown that there was a causal connection between the service-connected disability and the veteran's death. 38 C.F.R. § 3.312(b) and (c). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Once the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. 38 U.S.C.A. § 5107 (West 1991 and Supp. 2001); Ortiz v. Principi, 274 F.3d 1361, 1365-66 (Fed. Cir. 2001); 38 C.F.R. § 3.102 (as amended by 66 Fed. Reg. 45,620 (Aug. 29, 2001)). Analysis The original death certificate indicates that the veteran's death was caused by sepsis. No other underlying diseases or contributing causes were shown. "Sepsis" is defined as the presence in the blood or other tissues of pathogenic microorganisms or their toxins. Dorland's Illustrated Medical Dictionary 1507 (27th Ed.). Although the death certificate was revised approximately three years later to include additional disorders as causing death, the additional disorders were added by the staff of Casualty/Mortuary Affairs, based on the appellant's request, and there is no evidence of a medical determination having been made that the additional disorders in fact were the underlying or contributing causes of death. The veteran's attending physician signed the original death certificate, but there is no indication that he subsequently determined that the additional disorders caused the veteran's death or that he authorized the changes made in 1995. The Board finds, therefore, that the revision to the death certificate is of low probative value in determining the cause of death. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993) (lay persons are not competent to provide evidence of medical causation). Based on review of the evidence pertaining to the veteran's final hospitalization, Dr. Hill concluded that the veteran's death had been caused by sepsis, and that no other impairment contributed significantly to cause his death. Dr. Hill supported that conclusion with analysis of the medical evidence, and it is highly probative. Dr. Bash also concluded that the veteran's death was caused by sepsis. He also found that hypertension had contributed to cause the death on the basis that, in the absence of hypertension and the resulting stroke, the veteran would not have been hospitalized and would not have contracted the sepsis. That conclusion is speculative, however, in that the medical evidence indicates that the cause of the sepsis could not be determined. Dr. Bash did not provide any opinion regarding the specific cause of the sepsis, nor did he cite to any medical evidence establishing the cause. With the etiology of the sepsis undetermined, it is unknown whether the veteran contracted the microorganisms prior to entering the hospital, incidentally to being in the hospital, or as a direct result of being hospitalized. Dr. Bash also found that gouty arthritis and a back disorder that had been incurred in service contributed to cause the veteran's death. That opinion is also speculative, in that he based the opinion on the conclusion that the musculoskeletal disorders had prevented the veteran from exercising, thereby increasing the risk of developing a cardiovascular disease, including hypertension. The claims file is, however, devoid of any evidence regarding the veteran's lifestyle in terms of his exercise habits. Although the appellant testified that he had ongoing musculoskeletal complaints that at times affected his daily activities, there is no evidence indicating that the musculoskeletal disorders prevented him from exercising, or that in his case the failure to exercise significantly increased the risk of developing hypertension. Dr. Bash did not define the risk factors contributing to the development of cardiovascular disease, or discuss the applicability of any other risk factors and their relative significance. In order to establish service connection for the cause of death, it is not sufficient to show that a disease or injury casually shared in producing death; it must be shown that a direct causative relationship existed between a disability that was incurred in service and the veteran's death. Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991); 38 C.F.R. § 3.312(c). Assuming that the sepsis that caused the veteran's death was contracted while he was hospitalized, and assuming that hypertension was incurred in service, those facts do not establish a direct causative relationship between hypertension and the sepsis. In addition, assuming that a chronic musculoskeletal disorder was incurred in service, that assumption does not reflect a direct causative relationship between the musculoskeletal disorder and the sepsis. The Board finds, therefore, that Dr. Bash's opinion is not probative of a direct causative relationship between the cause of death and a service-connected disability. See Van Slack v. Brown, 5 Vet. App. 499, 502 (1993) (evidence is not probative if it does not show that a service-connected disorder caused, rather than was a contributing factor to, the death of the veteran). For these reasons the Board finds that the original death certificate and opinion by Dr. Hill are more probative than the amendment to the death certificate and the opinion provided by Dr. Bash. See Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999) (unpublished decision), cert. denied 120 S. Ct. 1251 (2000) (it is not error for the Board to value one medical opinion over another, as long as a rationale basis for doing so is given). The preponderance of the evidence shows, therefore, that the veteran's death was caused by sepsis, and that no other disease caused or substantially or materially contributed to cause his death. The veteran's service medical records are silent for any complaints or clinical findings related to sepsis, and the appellant does not claim otherwise. She asserts that he had a number of medical problems that had their onset during service, which combined to cause his death. As a lay person the appellant is competent to provide evidence of observable symptoms. Savage v. Gober, 10 Vet. App. 488, 496 (1997). She is not, however, competent to relate those symptoms to a given diagnosis, or to provide the etiology of a medical disorder. Her assertions, and those of her son, are not, therefore, probative of a relationship between a service- connected disorder and the veteran's death. At the time of the veteran's death, service connection had not been established for any disorder. Based on review of the evidence in the claims file, Dr. Hill concluded that chronic hypertension, diabetes mellitus, a chronic pulmonary disorder, and hypertensive renal disease were not shown during service. Although Dr. Bash found that gouty arthritis had its onset during service, he based that opinion on the finding of left knee effusion in December 1964. Diagnostic testing at that time, however, did not reveal elevated uric acid, and no diagnosis of gout was then made. There is no further reference in the medical records to the veteran having gout until September 1986, more than 20 years following his separation from service. Dr. Bash also found that hypertension had its onset during service, based on the elevated blood pressure recorded in April 1964. As Dr. Bash pointed out in his opinion, however, a single blood pressure reading cannot be relied upon in establishing or ruling out a diagnosis of hypertension. In accordance with 38 C.F.R. § 3.104, Diagnostic Code 7101, a diagnosis of hypertension requires readings to be taken two or more times per day on at least three different days. None of the veteran's blood pressure readings prior or subsequent to April 1964 were elevated, nor was a diagnosis of hypertension entered. There is no medical documentation of the veteran having hypertension until September 1986, more than 20 years following his separation from service. Although the September 1986 treatment record shows a 20 years history of hypertension, that finding was apparently based on the veteran's reported history, in that no reference was made to contemporaneous medical records, and is not probative of the onset of hypertension. See Godfrey v. Brown, 8 Vet. App. 113, 121 (1995) (an opinion that is based on the veteran's recitation of medical history is of no probative value). For the reasons shown above the Board also finds that a disorder that was incurred in service, or during the one year presumptive period following the veteran's separation from service, did not cause or substantially or materially contribute to cause his death. The Board has determined, therefore, that the preponderance of the evidence is against the claim of entitlement to service connection for the cause of the veteran's death. (continued on next page) ORDER The claim of entitlement to service connection for the cause of the veteran's death is denied. Michael A. Pappas Acting Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.