WAC 246-491-149   Information collected on the legal or public section of certificates; modifications to the United States standard certificates and report forms.  (1) Effective January 1, 2003, the department shall use the 2003 revisions of the United States standard forms for live birth and fetal death.

     (2) Effective January 1, 2004, the department shall use the 2003 standard form for death.

     (3) Effective January 1, 1992, the department shall use the 1988 revisions of the United States standard forms for marriage and certificate of divorce, dissolution of marriage or annulment.

     (4) These forms are developed by the United States Department of Health and Human Services, National Center for Health Statistics. Copies of these forms may be obtained by contacting the department's center for vital statistics.

     (5) With the exception of the confidential section, the department may modify any part of these forms.

     (a) Table 3 identifies the modifications to the United States standard form for live birth.

     (b) Table 4 identifies the modifications to the United States standard form for fetal death.

     (c) Table 5 identifies the modifications to the United States standard form for death.

     (d) Table 6 identifies modifications to the United States standard form for marriage.

     (e) Table 7 identifies modifications to the United States standard form for certificate of divorce, dissolution of marriage, or annulment.

     (6) Table 8 lists items to be collected on the certificate of dissolution of Washington state domestic partnership. This is a Washington state form not addressed in the United States standard forms.


U.S. STANDARD CERTIFICATE OF LIVE BIRTH
Table 3:

Legal or Public Birth Certificate Items
Item Number Item Name Difference from U.S. Standard, if any
1 Child's name  
2 Child's date of birth  
3 Time of birth  
4 Type of birthplace Add "En route," Add "Planned birthplace if different"
5 Child's sex  
6 Name of facility  
7 City, town or location of birth  
8 County of birth  
9 Mother's name before first marriage  
10 Mother's date of birth  
11 Mother's birthplace  
12 Mother's Social Security number  
13 Mother's current legal last name  
14 Social Security number requested for child?  
16a Mother's residence - number, street, and Apt. No.  
16b Mother's residence - city or town  
16c Mother's residence - county  
16d Tribal reservation name (if applicable) Added
16e Mother's residence - state or foreign country  
16f Mother's residence - zip code + 4  
16g Mother's residence - inside city limits?  
17 Telephone number Added
18 How long at current residence? Added
19 Mother's mailing address, if different  
25 Father's current legal name  
26 Father's date of birth  
27 Father's birthplace  
28 Father's Social Security number  
66 Certifier name and title Delete check boxes
67 Date certified  
68 Attendant name and title Delete check boxes
69 NPI of person delivering the baby  
--- Date filed by registrar Deleted


U.S. STANDARD REPORT OF FETAL DEATH
Table 4:

Legal or Public Fetal Death Certificate Items
Item Number Item Name Difference from U.S. Standard, if any
1 Name of fetus  
2 Sex  
3 Date of delivery  
4 Time of delivery  
5 Type of birthplace Add "En route," Add "Planned birthplace if different"
6 Name of facility  
7 Facility ID (NPI)  
8 City, town or location of birth  
9 Zip code of delivery  
10 County of birth  
11 Mother's name before first marriage  
12 Mother's date of birth  
13 Mother's current legal last name  
14 Mother's birthplace  
15a Mother's residence - number, street, and Apt. No.  
15b Mother's residence - city or town  
15c Mother's residence - county  
15d Tribal reservation name (if applicable) Added
15e Mother's residence - state or foreign country  
15f Mother's residence - zip code + 4  
15g Mother's residence - inside city limits?  
16 How long at current residence? Added
17 Father's current legal name  
18 Father's date of birth  
19 Father's birthplace  
20 Name and title of person completing the report  
21 Date report completed  
22 Attendant name and title Delete check boxes
23 NPI of person delivering the baby  
24 Method of disposition  
25 Date of disposition  
26 Place of disposition Added
27 Location of disposition - city/town and state Added
28 Name and complete address of funeral facility Added
29 Funeral director signature Added
30 Initiating cause/condition (cause of death)  
31 Other significant causes or conditions  
32 Estimated time of fetal death  
33 Was an autopsy performed?  
34 Was a histological placental examination performed?  
35 Were autopsy or histological placental examination results used in determining the cause of death?  
36 Registrar signature Added
37 Date received  


U.S. STANDARD CERTIFICATE OF DEATH
Table 5:

Death Certificate Items
Item Number Item Name Difference from U.S. Standard, if any
1 Legal name (include a.k.a.'s if any)
2 Death date
3 Sex
4a Age - years
4b Age - under 1 year
4c Age - under 1 day
5 Social Security number
6 County of death
7 Birth date
8a Birth place - city, town or county
8b Birth place - state or foreign country
9 Decedent's education Add "Specify": next to box for "8th Grade or less"
10 Decedent's Hispanic origin
11 Decedent's race
12 Was decedent ever in U.S. Armed Forces?
13a Residence - number and street
13b Residence - city or town
13c Residence - county
13d Tribal reservation name (if applicable) Added
13e Residence - state or foreign country
13f Residence - zip code
13g Inside city limits?
14 Estimated length of time at residence Added
15 Marital status at time of death
16 Surviving spouse's name
17 Occupation
18 Kind of business/industry
19 Father's name
20 Mother's name before first marriage
21 Informant - name
22 Informant - relationship to decedent
23 Informant - address
24 Place of death
25 Facility name (if not a facility, give number and street)
26a City, town, or location of death
26b State of death
27 Zip code of death
28 Method of disposition
29 Place of disposition (name of cemetery, crematory, other place)
30 Disposition - city/town, and state
31 Name and complete address of funeral facility
32 Date of disposition Added
33 Funeral director signature
34 Causes of death and intervals between onset and death
35 Other significant conditions contributing to death
36 Autopsy?
37 Were autopsy findings available to complete the cause of death?
38 Manner of death
39 Pregnancy status
40 Did tobacco use contribute to death?
41 Date of injury
42 Hour of injury
43 Place of injury
44 Injury at work?
45 Injury location - street, city, county, state, zip County Added
46 Describe how injury occurred
47 Transport injury type
48a Certifying physician signature
48b Medical examiner/coroner signature
49 Name and address of certifier
50 Hour of death
51 Name and title of attending physician if other than certifier Added
52 Date certified
53 Title of certifier
54 License number of certifier
55 ME/coroner file number Added
56 Was case referred to medical examiner?
57 County registrar signature Added
58 County date received Added
59 Record amendment Added
-- License number of funeral director Deleted
-- Date pronounced dead Deleted
-- Time pronounced dead Deleted
-- Signature of person pronouncing death Deleted
-- License number of person pronouncing death Deleted
-- Date person pronouncing death signed Deleted


U.S. STANDARD LICENSE AND CERTIFICATE OF MARRIAGE
Table 6:

Certificate of Marriage
Item Number Item Name Difference from U.S. Standard, if any
-- Certificate name Changed name of form to "Certificate of Marriage”
-- County of license
-- Date valid
-- Not valid after (date)
1 Date of marriage
2 County of ceremony
3 Type of ceremony Added
4 Date signed (by officiant) Added
5 Officiant's name
6 Officiant's signature
7 Officiant's address
8 Groom's name
9 Groom's address (street)
10 Groom's date of birth
11 Groom's place of birth (state or country)
12 Groom's address (city)
13 Groom's address (inside city limits) Added
14 Groom's address (county)
15 Groom's address (state)
16 Groom's father - name
17 Groom's father - place of birth
18 Groom's mother - maiden name
19 Groom's mother - place of birth
20 Groom's signature
21 Date signed (by groom)
22 Bride's name
23 Bride's maiden last name
24 Bride's residence - (street)
25 Bride's date of birth
26 Bride's place of birth (state or country)
27 Bride's residence (city)
28 Bride's residence (inside city limits) Added
29 Bride's residence (county)
30 Bride's residence (state)
31 Bride's father - name
32 Bride's father - place of birth
33 Bride's mother - maiden name
34 Bride's mother - place of birth
35 Bride's signature
36 Date signed (by bride)
37 Witness #1 signature
38 Witness #2 signature
39 County auditor signature
40 Date received (by county auditor)
Reverse side Groom's Social Security number
Reverse side Bride's Social Security number
  Groom's age last birthday Deleted
  Bride's age last birthday Deleted
  License to marry section Deleted
  Expiration date of license Deleted
  Title of issuing official Deleted
  Confidential information Deleted


U.S. STANDARD CERTIFICATE OF DIVORCE, DISSOLUTION OF MARRIAGE, OR ANNULMENT
TABLE 7:

Certification of Dissolution, Declaration of Invalidity of Marriage, or Legal Separation
Item Number Item Name Difference from U.S. Standard, if any
Certificate name Changed form name to certificate of dissolution, declaration of invalidity of marriage or legal separation
  Court file number  
1 Type of decree Added check boxes
2 Date of filing  
3 County where decree filed  
4 Signature of superior court clerk  
5 Husband's name  
6 Husband's date of birth  
7 Husband's place of birth  
8 Husband's residence - street  
9 Husband's residence - city  
10 Husband's residence - inside city limits Added
11 Husband's residence - county  
12 Husband's residence - state  
13 Wife's name  
14 Wife's maiden name  
15 Wife's date of birth  
16 Wife's place of birth  
17 Wife's residence - street  
18 Wife's residence - city  
19 Wife's residence - inside city limits Added
20 Wife's residence - county  
21 Wife's residence - state  
22 Place of marriage - county  
23 Place of marriage - state  
24 Date of marriage  
25 Number of children of this marriage Name change
26 Petitioner Delete check boxes
27 Name of petitioner's attorney/pro se  
28 Petitioner's address  
29 Husband's Social Security number  
30 Wife's Social Security number  
  Date couple last resided in same household Delete
  Number of children under 18 whose physical custody was awarded to Delete
  Title of court Delete
  Title of certifying official Delete
  Date signed Delete
  Confidential information Delete


TABLE 8:

Certification of Dissolution of Washington State Domestic Partnership
Item Number Item Name
Certificate name
  Court file number
1 Type of decree
2 Date of decree
3 County where decree filed
4 Signature of superior court clerk
5a First partner's name
5b First partner's name at birth
6 First partner's date of birth
7 First partner's place of birth
8 First partner's residence - street
9 First partner's residence - city
10 First partner's residence - inside city limits
11 First partner's residence - county
12 First partner's residence - state
13a Second partner's name
13b Second partner's name at birth
14 Second partner's date of birth
15 Second partner's place of birth
16 Second partner's residence - street
17 Second partner's residence - city
18 Second partner's residence - inside city limits
19 Second partner's residence - county
20 Second partner's residence - state
21 Date of this partnership
22 Domestic partnership certificate number
23 Petitioner
24 Name of petitioner's attorney/pro se
25 Petitioner's address




[Statutory Authority: RCW 26.09.150. 09-11-111, § 246-491-149, filed 5/19/09, effective 6/19/09. Statutory Authority: RCW 43.70.150, 70.58.055, and chapter 70.58 RCW. 02-20-092, § 246-491-149, filed 10/1/02, effective 11/1/02. Statutory Authority: RCW 43.70.150. 91-23-026 (Order 211), § 246-491-149, filed 11/12/91, effective 12/13/91. Statutory Authority: RCW 43.70.040. 91-02-049 (Order 121), recodified as § 246-491-149, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20A.620. 88-19-034 (Order 2696), § 248-124-160, filed 9/12/88.]