It has taken three death certificates and one revision, but the relatives of Margaret T. Lesch finally believe they know why she died in a hospital here last Nov. 4. The state medical examiner has ruled that she bled to death after a surgeon accidentally cut her jugular vein while inserting a catheter during abdominal surgery.

But that is not what Lesch's family originally was told. The first death certificate filled out by doctors at the University of Maryland Hospital said that Lesch, 67, died of a cardiac arrest of unknown origin while she was in the operating room. When an Ellicott City undertaker said the certificate was filled out incompletely, hospital doctors filled out another that listed the same cause of death.

The undertaker then took Lesch's death certificate to the state medical examiner's office. An assistant medical examiner there said he wrote "Void" across the certificate and, after speaking with doctors at the hospital, filled out a third death certificate saying again that Lesch died of cardiac arrest.

But when Lesch's husband later told an assistant medical examiner that his wife, who was in the hospital for pancreas surgery, had nothing wrong with her heart, an investigation began that concluded Lesch bled to death.

The assistant state medical examiner, Dr. Gregory Kauffman, said there was nothing unusual about an elderly patient suffering a heart attack during surgery. But he said he was impressed with the "sincerity" of Lesch's husband.

"I was able to locate the people involved and get hold of the autopsy findings," Kauffman said. "They clearly demonstrated a tear in the major vein, draining blood out of the head. I looked at the photos that were taken, and there was substantial hemorrhaging around the site of the tear. I confirmed the records in conversations I had with several physicians that had been involved."

"I had no doubt that the information was intentionally withheld from me -- the information concerning the hemorrhaging," Kauffman added, "because I was never told of any problems whatsoever with the catheter placement, and I was never told of the hemorrhaging that occurred. There's no way that could be anything but intentional."

Kauffman revised the third death certificate on Jan. 14.

Lesch's husband, Gerard A. Lesch, a retired dentist from Hilton Head, S.C., declined to comment on the case, referring questions to his attorney Marvin Ellin. Ellin said he found it "difficult to understand" why the hole in Lesch's jugular vein could not have been repaired before she bled to death. The cause of death listed on the first three death certificates, he said, was "equally shocking."

Gerard Lesch has filed a claim naming the hospital and four doctors: H. Harlan Stone, who is director of surgery at the hospital; James M. Carlton and Brad Lerner, the two doctors who performed the surgery, and Thomas J. O'Loughlin, who filled out the first two death certificates. Neither Stone, who is out of the country, nor O'Loughlin, who is on vacation, could be reached for comment. Lerner said he could not comment because a claim has been filed, while Carlton could not be reached.

Joan Shnipper, a representative of the hospital, said officials there declined to comment because a claim had been filed.

According to the account of events described by Ellin and papers filed today by Gerard Lesch in the Health Claims Arbitration Office seeking unspecified damages from hospital doctors, Margaret Lesch came to the University of Maryland Hospital in Baltimore for her operation because a daughter lived nearby and because of the reputation of Dr. Harlan Stone, who has received much publicity for pioneering the use in this country of zippers in pancreas surgery.

Stone did not perform the operation on Lesch.

Lesch's surgery was completed satisfactorily, as were several routine follow-up operations. But on Oct. 30, Gerard Lesch alleges, things went wrong in a skin graft operation to repair skin damage from the earlier operations.

The doctors inserted a catheter into a jugular vein in Lesch's neck, according to the claim, to provide supplemental nourishment. The doctors lacerated the surface of the vein, the claim continues, and failed to repair or seal off the vein until Lesch had lost four quarts of blood: 60 percent of the human body's blood volume. By that time her brain and spinal cord were deprived of oxygen, causing the heart and lungs to stop working, according to the claim.

By the time that Lesch was revived, according to the claim, she was brain dead and dependent on life-support systems. She was pronounced dead Nov. 4.

Gerard Lesch was told by doctors that his wife had suffered a cardiac arrest on the operating table but they did not know why, according to the claim he has filed. He claims in the complaint that the doctors "deliberately attempted to make the death" of his wife "appear as if she had succumbed to natural causes."