Washington Administrative Code › Title 246 - Health, Department of › HEALTH INFORMATION › Chapter 246-491 - Vital statistics - Certificates › Section 246-491-149 - Information collected on the legal or public section of vital records

Current through Register Vol. 24-14, July 15, 2024
The department shall collect the following items on the
				  legal or public section of reports for registration into the statewide vital
				  records system in accordance with chapter 70.58A RCW and this section.
REPORT OF LIVE BIRTH
Table 3: Legal or Public Birth Record
				  Items
Item Name
Difference from
U.S. Standard,
if any
Child's name
Child's date of birth
Time of birth
Type of birthplace
Add "En route," Add "Planned birthplace if different"
Child's sex
Name of facility
City, town or location of birth
County of birth
Mother/ Parent's name before first marriage
Mother/ Parent's date of birth
Mother/ Parent's birthplace
Mother/ Parent's Social Security number
Mother/ Parent's current legal last name
Social Security number requested for child?
Mother/ Parent's residence - Number, street, and Apt.
Mother/ Parent's residence - City or town
Mother/ Parent's residence -County
Tribal reservation name (if applicable)
Added
Mother/ Parent's residence - State or foreign country
Mother/ Parent's residence - Zip code + 4
Mother/ Parent's residence -Inside city limits?
Telephone number
Added
How long at current residence?
Added
Mother/ Parent's mailing address, if different
Father/ Parent's current legal name
Father/ Parent's date of birth
Father/ Parent's birthplace
Father/ Parent's Social Security number
Certifier name and title
Delete check boxes
Date certified
Attendant name and title
Delete check boxes
NPI of person delivering the baby
REPORT OF FETAL DEATH
Table 4: Legal or Public Fetal Death Record
				  Items
Item Name
Difference from U.S. Standard, if any
Name of fetus
Sex
Date of delivery
Time of delivery
Type of birthplace
Add "En route," Add "Planned birthplace if different"
Name of facility
Facility ID (NPI)
City, town or location of birth
Zip code of delivery
County of birth
Mother/ Parent's name before first marriage
Mother/ Parent's date of birth
Mother/ Parent's current legal last name
Mother/ Parent's birthplace
Mother/ Parent's residence -Number, street, and Apt.
Mother/ Parent's residence - City or town
Mother/ Parent's residence -County
Tribal reservation name (if applicable)
Added
Mother/ Parent's residence - State or foreign country
Mother/ Parent's residence - Zip code + 4
Mother/ Parent's residence -Inside city limits?
How long at current residence?
Added
Father/ Parent's current legal name
Father/ Parent's date of birth
Father/ Parent's birthplace
Name and title of person completing the report
Date report completed
Attendant name and title
Delete check boxes
NPI of person delivering the baby
Method of disposition
Date of disposition
Place of disposition
Added
Location of disposition - City/town and state
Added
Name and complete address of funeral facility
Added
Funeral director signature
Added
Initiating cause/condition (cause of death)
Other significant causes or conditions
Estimated time of fetal death
Was an autopsy performed?
Was a histological placental examination performed?
Were autopsy or histo-logical placental examination
						  results used in determining the cause of death?
Registrar signature
Added
Date received
REPORT OF DEATH
Table 5: Death Record Items
Item Name
Difference from U.S. Standard, if any
Legal name (include a.k.a. if any)
Death date
Sex
Add "X" as non-binary option
Age - Years
Age - Under 1 year
Age - Under 1 day
Social Security number
County of death
Birth date
Birth place - City, town or county
Birth place - State or foreign country
Decedent's education
Add "Specify": next to box for "8th Grade or less"
Decedent's Hispanic
Decedent's race
Was decedent ever in U.S. Armed Forces?
Residence - Number and street
Residence - City or town
Residence - County
Tribal reservation name (if applicable)
Added
Residence - State or foreign country
Residence - Zip code
Inside city limits?
Estimated length of time at residence
Added
Marital status at time of
Surviving spouse's name
Occupation
Kind of business/ industry
Father/ Parent's name
Mother/ Parent's name before first marriage
Informant - Name
Informant - Relationship to decedent
Informant - Address
Place of death
Facility name (if not a facility, give number and
						  street)
City, town, or location of death
State of death
Zip code of death
Method of disposition
Place of disposition (name of cemetery, crematory, other
						  place)
Disposition - City/town, and state
Name and complete address of funeral facility
Date of disposition
Added
Funeral director signature
Causes of death and intervals between onset and death
Other significant conditions contributing to death
Autopsy?
Were autopsy findings available to complete the cause of
						  death?
Manner of death
Pregnancy status
Did tobacco use contribute to death?
Date of injury
Hour of injury
Place of injury
Injury at work?
Injury location - Street,
County Added
city, county, state, zip
Describe how injury occurred
Transport injury type
Certifying physician signature
Medical examiner/coroner signature
Name and address of certifier
Hour of death
Name and title of attending physician if other than
						  certifier
Added
Date certified
Title of certifier
License number of certifier
ME/coroner file number
Added
Was case referred to medical examiner?
County registrar signature
Added
County date received
Added
Record amendment
Added
REPORT OF MARRIAGE
Table 6: Certification of Marriage
Item Name
Difference from
U.S. Standard,
if any
Certificate name
Modified
County of license
Added
Date valid
Not valid after (date)
County auditor signature
Date received (by county auditor)
Person A -Bride/groom/spouse
Added
Legal name before marriage
Modified
Birth name, if different
Added
Sex
Added
Current residence (street, city/town)
County of residence
State of residence
Date of birth
Birth state (if not USA, provide country)
Mother/Parent's birth name
Modified
Father/Parent's birth name
Modified
Mother/Parent's birth state (or country)
Modified
Father/Parent's birth state (or country)
Modified
Person B -Bride/groom/spouse
Added
Legal name before marriage
Birth name, if different
Modified
Sex
Added
Current residence (street, city/town)
County of residence
State of residence
Date of birth
Birth state (if not USA, provide country)
Mother/Parent's birth name
Modified
Father/Parent's birth
Modified
Mother/Parent's birth state (or country)
Modified
Father/Parent's birth state (or country)
Modified
Date of marriage
County of ceremony
Type of ceremony
Added
Date signed (by officiant)
Added
Officiant's address
Officiant's daytime phone
Added
Officiant's name
Officiant's signature
Witness signature
Witness signature
Person A signature
Modified
Date signed (by person A)
Added
Person B signature
Modified
Date signed (by person B)
Added
Person A - Social Security number
Added
Person A - Name
Added
Person B - Social Security number
Added
Person B - Name
Added
Person A signature -Declaration in absence of a Social
						  Security number
Added
Person A date - Declaration in absence of a Social
						  Security number
Added
Person B signature -Declaration in absence of a Social
						  Security number
Added
Person B date - Declaration in absence of a Social
						  Security number
Added
REPORT OF DIVORCE, DISSOLUTION OF MARRIAGE, OR
				  ANNULMENT
Table 7:
Certification of Dissolution, Declaration of Invalidity
				  of Marriage, or Legal Separation
Item Name
Difference from U.S. Standard, if any
Certificate name
Modified
Court file number
Added
Type of decree
Date of decree
County where decree
Signature of superior court clerk
Spouse A - Name
Added
Birth name, if different
Added
Date of birth
Place of birth (state or country)
Residence - Street
Added
Residence - City
Residence - County
Residence - State
Spouse B - Name
Added
Birth name, if different
Modify
Date of birth
Place of birth (state or country)
Residence - Street
Added
Residence - City
Residence - County
Residence - State
Place of marriage -County
Place of marriage - State
Date of marriage
Number of children born alive of this marriage
Added
Petitioner
Name of petitioner's attorney or pro se
Petitioner's attorney's address
Spouse A Social Security number
Added
Spouse B Social Security number
Added
Table 8: Certification of Dissolution of Washington
				  State Domestic Partnership
Item Name
Certificate name
Court file number
Type of decree
Date of decree
County where decree filed
Signature of superior court clerk
First partner's name
First partner's name at birth
First partner's date of birth
First partner's place of birth
First partner's residence - Street
First partner's residence - City
First partner's residence - Inside city limits
First partner's residence - County
First partner's residence - State
Second partner's name
Second partner's name at birth
Second partner's date of birth
Second partner's place of birth
Second partner's residence - Street
Second partner's residence - City
Second partner's residence - Inside city limits
Second partner's residence - County
Second partner's residence - State
Date of this partnership
Domestic partnership certificate number
Petitioner
Name of petitioner's attorney/pro se
Petitioner's address
Statutory Authority:
					 RCW
					  43.70.150. 13-01-004, § 246-491-149,
					 filed 12/6/12, effective 12/6/12. 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.