246-491-039  <<  246-491-149 >>   246-491-990

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.
(7) Modification to the United States standard form for marriage for parties who previously had a state-registered domestic partnership. Parties who previously had a state-registered domestic partnership and become married in Washington may obtain an amended marriage certificate from the state registrar that includes the legal date of marriage. Marriage certificates issued to parties who have a state-registered domestic partnership and who are deemed married under RCW 26.60.100 shall include the legal date of marriage of the parties. The legal date of marriage is defined in RCW 26.60.100(4) as the date of the original state-registered domestic partnership.
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. 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
Modified
1
County of license
Added
2
Date valid
 
3
Not valid after (date)
 
4
County auditor signature
 
5
Date received (by county auditor)
 
6a
Person A - Bride/groom/spouse
Added
6b
Legal name before marriage
Modified
6c
Birth name, if different
Added
6d
Sex - Male/female
Added
6e
Current residence (street, city/town)
 
6f
County of residence
 
6g
State of residence
 
6h
Date of birth
 
6i
Birth state (if not USA, provide country)
 
6j
Mother/parent birth name
Modified
6k
Father/parent birth name
Modified
6l
Mother/parent birth state (or country)
Modified
6m
Father/parent birth state (or country)
Modified
7a
Person B - Bride/groom/spouse
Added
7b
Legal name before marriage
 
7c
Birth name, if different
Modified
7d
Sex - Male/female
Added
7e
Current residence (street, city/town)
 
7f
County of residence
 
7g
State of residence
 
7h
Date of birth
 
7i
Birth state (if not USA, provide country)
 
7j
Mother/parent birth name
Modified
7k
Father/parent birth name
Modified
7l
Mother/parent birth state (or country)
Modified
7m
Father/parent birth state (or country)
Modified
8
Date of marriage
 
9
County of ceremony
 
10
Type of ceremony
Added
11
Date signed (by officiant)
Added
12
Officiant's address
 
13
Officiant's daytime phone
Added
14
Officiant's name
 
15
Officiant's signature
 
16
Witness signature
 
17
Witness signature
 
18
Person A signature
Modified
19
Date signed (by person A)
Added
20
Person B signature
Modified
21
 
Date signed (by person B)
Added
22
Person A - Social Security number
Added
23
Person A - Name
Added
24
Person B - Social Security number
Added
25
Person B - Name
Added
26
Person A signature - Declaration in absence of a Social Security number
Added
27
Person A date - Declaration in absence of a Social Security number
Added
28
Person B signature - Declaration in absence of a Social Security number
Added
29
Person B date - Declaration in absence of a Social Security number
Added
 
(Groom's) age last birthday
Deleted
 
(Bride's) age last birthday
Deleted
 
Signature of (license) issuing official
Deleted
 
Title of (license) issuing official
Deleted
 
Where married - City, town or location
Deleted
 
Title (of officiant)
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
Modified
1
Court file number
Added
2
 
Type of decree
 
3
Date of decree
 
4
County where decree filed
 
5
Signature of superior court clerk
 
6a
Spouse A - Name
Added
6b
Birth name, if different
Added
6c
Date of birth
 
6d
Place of birth (state or country)
 
6e
Residence - Street
Added
6f
Residence - City
 
6g
Residence - County
 
6h
Residence - State
 
7a
Spouse B - Name
Added
7b
Birth name, if different
Modify
7c
Date of birth
 
7d
Place of birth (state or country)
 
7e
Residence - Street
Added
7f
Residence - City
 
7g
Residence - County
 
7h
Residence - State
 
8
Place of marriage -County
 
9
Place of marriage - State
 
10
Date of marriage
 
11
Number of children born alive of this marriage
Added
12
Petitioner
 
13
Name of petitioner's attorney or pro se
 
14
Petitioner's attorney's address
 
15
Spouse A Social Security number
Added
16
Spouse B Social Security number
Added
 
Date (decree) recorded
Deleted
 
Number of children under 18 whose physical custody was awarded to (husband, wife, joint, other)
Deleted
 
Number of children under 18 in household
Deleted
 
Title of court
Deleted
 
Title of certifying official
Deleted
 
Date (certifying official) signed
Deleted
 
Date couple last resided in same household
Deleted
 
Confidential items
Deleted
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 43.70.150 and 26.60.100. WSR 14-04-092, § 246-491-149, filed 2/4/14, effective 3/7/14. Statutory Authority: RCW 43.70.150. WSR 13-01-004, § 246-491-149, filed 12/6/12, effective 12/6/12. Statutory Authority: RCW 26.09.150. WSR 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. WSR 02-20-092, § 246-491-149, filed 10/1/02, effective 11/1/02. Statutory Authority: RCW 43.70.150. WSR 91-23-026 (Order 211), § 246-491-149, filed 11/12/91, effective 12/13/91. Statutory Authority: RCW 43.70.040. WSR 91-02-049 (Order 121), recodified as § 246-491-149, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 43.20A.620. WSR 88-19-034 (Order 2696), § 248-124-160, filed 9/12/88.]
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