PERMANENT RULES
Effective Date of Rule: Thirty-one days after filing.
Purpose: The change adds a form for the courts to file a record of a dissolution of a domestic partnership. The rule adds the details of the new form to the existing rule concerning vital records. This makes it consistent with the documentation of details of all other vital records forms.
Citation of Existing Rules Affected by this Order: Amending WAC 246-491-149.
Statutory Authority for Adoption: RCW 26.09.150.
Adopted under notice filed as WSR 09-07-052 on March 11, 2009.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: May 19, 2009.
Mary C. Selecky
Secretary
OTS-2096.2
AMENDATORY SECTION(Amending WSR 02-20-092, filed 10/1/02,
effective 11/1/02)
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((s)) 3((, 4, and 5 identify)) identifies the
modifications to the United States standard form((s)) for live
birth((, fetal death, and death)).
(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((s)) 6 ((and 7 identify)) identifies
modifications to the United States standard form for
marriage((, and certificate of divorce, dissolution of
marriage, or annulment)).
(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 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.]