PROPOSED RULES
(Department of Health)
Original Notice.
Preproposal statement of inquiry was filed as WSR 01-08-090.
Title of Rule: Chapter 246-491 WAC, Vital statistics -- Certificates.
Purpose: These rules identify the information that the Department of Health collects from birth, death, fetal death, marriage, divorce and separation certificates. The State Board of Health identifies the information collected from the confidential sections of these certificates, and the Department of Health identifies the information collected from the public section of the certificates.
Other Identifying Information: The information collected on the certificates is based on the United States forms of live birth and fetal death, which are developed by the United States Department of Health and Human Services, National Center for Health Statistics.
Statutory Authority for Adoption: WAC 246-491-001 Purpose is RCW 43.70.150, chapter 70.58 RCW; WAC 246-491-010 Definitions is RCW 43.70.150; WAC 246-491-029 Information collected on the confidential section of live birth and fetal death certificates and 246-491-039 Confidential information on state of Washington live birth and fetal death certificates under chapter 70.58 RCW is RCW 70.58.055; and WAC 246-491-149 Information collected on the legal or public section of certificates is RCW 43.70.150.
Statute Being Implemented: Chapter 70.58 RCW.
Summary: The proposal incorporates federal changes to birth, death, and fetal death certificates. The entire chapter is also reformatted to improve clarity.
Reasons Supporting Proposal: The proposal removes items that are no longer relevant, not being used, or that cannot be reliably collected. The proposal will enable the department to add items that address emerging health issues.
Name of Agency Personnel Responsible for Drafting: John Whitbeck, Center of Health Statistics, (360) 236-4321; Implementation: Phil Freeman, Center of Health Statistics, (360) 236-4330; and Enforcement: Teresa Jennings, Center of Health Statistics, (360) 236-4307.
Name of Proponent: State Board of Health, Washington Department of Health, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: The proposal incorporates federal changes to the birth, death, and fetal death certificates. The proposal removes items that are no longer relevant, not being used, or that cannot be reliably collected. The proposal adds items that address emerging health issues. The proposal also changes the format of the chapter so that it is easier to read and understand. The outcome of the rule change will be the collection of more relevant data, and increased clarity within the rule.
Proposal Changes the Following Existing Rules: The change adds new items, deletes some previously added, and deletes some items to birth, fetal death, and death certificates. The proposal also changes the format of the information described within the rule.
A small business economic impact statement has been prepared under chapter 19.85 RCW.
I. What does the rule or rule amendment require? The rule requires that hospitals, funeral directors, and certifiers of causes of death collect information for birth, fetal death and death certificates that are slightly different from the United States standard certificates, but each on a form that is constructed and delivered by the Center for Health Statistics/DOH. The birth certificate data are collected by a web instrument form data that the hospitals and birthing centers generate on site from hospital records, and a work sheet filled in by parents.
The death certificate, which is being approved by this rule change, will not be in effect until January 1, 2004. Prior to that time, a mandatory legislative feasibility study on the proposed electronic collection of death certificates (EDRS) must be completed by December 31, 2002. This report to the legislature will discuss potential impacts, costs and savings of affected small businesses.
The rule to be amended defines the items included on vital statistics certificates provided by the Washington State Center for Health Statistics (CHS). This amendment is necessary because of recent changes in federal recommendations cited in Washington state law. RCW 70.58.055 requires CHS to use on its vital statistics certificates, at a minimum, the items recommended by the National Center for Health Statistics (NCHS). NCHS periodically revises its recommendations, to increase the relevance and quality of data collected on the certificates. Historically the national revision prompts a revision of state certificates, to ensure nation-wide comparability and take advantage of improvements suggested by national reviews of the certificate items. Implementation of these recommendations for the birth and fetal death certificates is expected to take effect in January 2003. Implementation for the death certificate will be January 1, 2004.
The current rule changes modify the certificates only slightly. All persons or business affected have filled in and submitted these certificates as a part of their business practice since beginning their business. Birth certificate data are collected by a web instrument from data that the hospitals and birthing centers generate onsite from hospital records, and a work sheet filled in by parents. The death certificate, which is being approved by this rule change, will not be in effect until January 1, 2004. The change will not affect the methods by which funeral directors collect their information, since they rely upon informants -- family members of the deceased, doctors, medical examiners, nursing home or hospital staff. However, additions, changes or deletions to each certificate were examined to determine if there are any disproportionate burdens to small business. There are two additions new to the certificate (tribal reservation name and county of injury). Based on other analyses, these items would add fifteen seconds to the completion time of each death certificate. There are six items deleted from the certificate (License number of funeral director, Date pronounced dead, Time pronounced dead, Signature of person pronouncing death, License number of person pronouncing death, and Date person pronouncing death signed). As a conservative estimate, the timesavings from the deletions would be at least thirty seconds per death certificate. Thus, the net change is fifteen seconds less for the new death certificate. For this reason, an item analysis for death certificates was not done.
Industries affected: This rule has been evaluated and the amendments may affect the following 4 digit SIC codes. Midwives and hospitals (8049, 8062, 8069) are affected primarily by the birth certificate requirements. The remaining SICs (7261, 8011, 8031), are affected primarily by the fetal death certificate.
7261 - Funeral homes
8049 - Midwives & Clinics of physician assistants
8062 - General medical & surgical hospitals
8069 - Cancer hospitals, chronic disease hospitals, maternity hospitals, etc.
8011 - Clinics of physicians & Pathologists
8031 - Clinics of osteopathic physicians
II. Rule costs: Most of the rule amendment costs are exempt due to the fact that the rule adopts a federal or state law by reference. The remaining costs involving those parts of the rules that delete or add items, which may not be exempt, have been analyzed based on the time required to fill out the added information.
Reporting Costs: All of the costs of the rule amendments are reporting. For a breakdown of the labor cost of the reporting requirements see Table 1. For a worst case analysis the labor cost of the reporting requirement for a large hospital is $1,582 and for a small hospital is $12.51 per year. The large hospital is assumed to have 4,967 births and the small birthing hospital is assumed to have sixteen births per year.1 Large hospitals generally have computer systems that automatically query for data and data entry is fast and done by a medical assistant with an hourly wage of $12.07. The small birthing centers may have the data entry done by the RN who helped with delivery. The average hourly wage for the RN is $24.22.2
The agency used an expert opinion3 to estimate the time it takes to enter data in the new data system that is being made available to all birthing centers.
The cost for fetal death certificates is minor. Since they are rare it is not considered here.
| Table 1 | ||||||||
| Estimate of Cost of Rule for proposed 2003 Washington State Birth Certificate and U.S. Standard Certificate |
||||||||
| Required by | Added | Large Hospitals | Small Hospitals | |||||
| Federal | DOH | time per | # Births/yr | 4967 | # Births/yr | 16 | ||
| Reg. | Prop. | Status | birth | Cost/birth1 | Total $ | Cost/birth2 | Total $ | |
| Changes to existing items: | ||||||||
| Place where birth occurred: add 'enroute' | Yes | -- | Exempt | |||||
| Mother married? Split into two questions: Is mother married to the father? If no, was mother married to anyone during this pregnancy? | Yes | -- | Exempt | -- | -- | -- | -- | |
| Mother's education: If 8th grade or less, add line to specify exact years of education | Yes | -- | Exempt | |||||
| Father's education: If 8th grade or less, add line to specify exact years of education | Yes | -- | Exempt | -- | -- | -- | -- | -- |
| Source of payment for delivery: Add 'Indian Health' and 'CHAMPUS' | Yes | -- | Exempt | |||||
| Risk factors in this pregnancy: Add 'Group B streptococcus culture positive' | Yes | -- | Exempt | -- | -- | -- | -- | -- |
| Infections present and/or treated during this pregnancy: Add 'HIV infection' and 'Other (specify)' | Yes | Exempt | -- | -- | -- | -- | -- | |
| Added items: | ||||||||
| Tribal reservation name (if applicable) | Yes | Eligible | 10 | 0.0335 | 166.39 | 0.0673 | 1.08 | |
| Mother's telephone number | Yes | Eligible | 5 | 0.0168 | 83.45 | 0.0336 | 0.54 | |
| Length of time at mother's current residence | Yes | Eligible | 5 | 0.0168 | 83.45 | 0.0336 | 0.54 | |
| Mother's occupation and industry | Yes | Eligible | 10 | 0.0335 | 166.39 | 0.0673 | 1.08 | |
| Father's occupation and industry | Yes | Eligible | 10 | 0.0335 | 166.39 | 0.0673 | 1.08 | |
| Optional signature line for person reviewing the worksheet | Yes | Eligible | 0 | 0 | 0 | 0 | 0 | |
| Infant head circumference | Yes | Eligible | 60 | 0.2012 | 999.36 | 0.4037 | 6.46 | |
| Deleted items: | ||||||||
| Date filed by registrar | Yes | Eligible | -5 | -0.0168 | -83.45 | -0.0336 | -0.54 | |
| Total | 95 | 0.3185 | 1581.99 | 0.6391 | 10.23 | |||
| 1Large hospital costs estimated based on work done by a "medical assistant," 31-9092, mean annual wage $12.07/hour. | ||||||||
| 2Small hospital costs estimated based on work done by a "registered nurse," 29-1111, mean annual wage $24.22/hour. | ||||||||
Given that the cost is disproportionate for small business DOH must minimize the costs.
IV. What cost minimizing features were included?
A. Reducing, modifying, or eliminating substantive regulatory requirements: DOH eliminated one item from the birth certificate, requiring the date filed by the registrar.
B. Simplifying, reducing, or eliminating record-keeping and reporting requirements: Making the computer system web accessible means that it is far easier for the hospitals and other users to maintain records and file them than it was.
C. Reducing the frequency of inspections: There are no inspections.
D. Delaying compliance timetables: There is no change but DOH has made it easier to comply on time with the new WEB system.
E. Reducing or modifying fine schedules for noncompliance: There are no fines.
V. How will you involve small business in the rule making? Information was sent to approximately 1,960 hospitals, birth centers and other interested parties. Information was also placed on the Department of Health website with forms for comment. Those without access to the internet may request a packet of information through the United States mail.
The same people and organizations will be notified of the hearing scheduled for September 11, 2002.
1Some hospitals have one or two births but these are generally emergencies.
2See sources on Table 1.
3Pat Starzyk, Research Investigator, Center for Health Statistics.
A copy of the statement may be obtained by writing to Suzanne Shillander, Center for Health Statistics, P.O. Box 47814, Olympia, WA 98504-7814, phone (360) 236-4308, fax (360) 753-4135.
RCW 34.05.328 does not apply to this rule adoption. Credentialed health care providers can be disciplined and sanctioned under RCW 18.130.180(7) of the Uniform Disciplinary Act for failing to comply with laws that apply to the practice of the particular profession. Because physicians and midwives are subject to the reporting requirements in RCW 70.58.080, this rule qualifies as legislatively significant.
Hearing Location: 2002 Mount Vernon Best Western Cottontree Inn & Conference Center, 2401 Riverside Drive, Mount Vernon, WA 98273, phone (360) 428-5678, fax (360) 848-5285, on September 11, 2002, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Desiree Robinson at (360) 236-4107, TDD (1) 800 or (833) 6388.
Submit Written Comments to: Suzanne Shillander, Center for Health Statistics, P.O. Box 47814, Olympia, WA 98504-7814, fax (360) 753-4135, by September 10, 2002.
Date of Intended Adoption: September 11, 2002.
August 1, 2002
M. C. Selecky, Secretary
August 2, 2002
Don Sloma, Director
OTS-5810.1
NEW SECTION
WAC 246-491-001
Purpose.
RCW 70.58.055 requires
certificates for vital records to include, at a minimum, items
recommended by the federal agency responsible for national vital
statistics. RCW 70.58.055 allows the state board of health to
require additional information for the confidential section of
the birth certificate, and eliminate items from the federal forms
that it identifies as not necessary for statistical study.
RCW 43.70.150 requires the secretary of the department of health to operate and maintain a state system for registering births, deaths, fetal deaths, marriages, divorce decrees, annulments and separations. RCW 43.70.160 requires the state registrar to prepare, print and supply the forms for registering, recording, and preserving vital statistics. These rules identify the forms used and information collected by the state on live birth, death, fetal death, marriage, divorce, dissolution of marriage and annulment.
[]
(1) "Board" means the state board of health.
(2) "Department" means the department of health.
[]
(2) Copies of these forms may be obtained by contacting the department's center for vital statistics.
(3) Tables 1 and 2 list the statistical information contained in the confidential sections of the birth and fetal death certificates that the board requires the department to collect, and the differences between the state and U.S. standard.
| Add "during pregnancy mother participated in (special programs).")) | |
| U.S. STANDARD CERTIFICATE OF LIVE BIRTH | ||
| TABLE 1: Confidential Birth Certificate Items |
||
| Item Number | Item Name | Difference from U.S. Standard, if any |
| 15 | Is mother married to the father? | |
| If no, was mother married to anyone during the pregnancy? | Added | |
| Has the paternity affidavit been signed? | ||
| 20 | Mother's education | Add "Specify": next to box for "8th Grade or less" |
| 21 | Mother of Hispanic origin? | |
| 22 | Mother's race | |
| 23 | Mother's occupation | Added |
| 24 | Mother's kind of business/industry | Added |
| 29 | Father's education | Add "Specify": next to box for "8th Grade or less" |
| 30 | Father of Hispanic origin? | |
| 31 | Father's race | |
| 32 | Father's occupation | Added |
| 33 | Father's kind of business/industry | Added |
| 34 | Mother's medical record number | |
| 35 | Mother's prepregnancy weight | |
| 36 | Mother's weight at delivery | |
| 37 | Mother's height | |
| 38 | Did mother get WIC food for herself during pregnancy? | |
| 39 | Cigarette smoking before and during pregnancy | |
| 40a | Number of previous live births | |
| 40b | Date of last live birth | |
| 41a | Number of other pregnancy outcomes | |
| 41b | Date of last other pregnancy outcome | |
| 42a | Date of first prenatal care visit | |
| 42b | Date of last prenatal care visit | |
| 43 | Total number of prenatal visits for this pregnancy | |
| 44 | Date last normal menses began | |
| 45 | Was mother transferred to higher-level care for maternal medical or fetal indications for delivery? | |
| 46 | Principal source of payment for this delivery | Add "Indian Health" and "CHAMPUS" |
| 47 | Newborn medical record number | |
| 48 | Birth weight | |
| 49 | Infant head circumference | Added |
| 50 | Obstetric estimate of gestation | |
| 51 | Apgar score at 5 min; if score is less than 6, score at 10 minutes | |
| 52 | Plurality | |
| 53 | If not single birth - born 1st, 2nd, 3rd etc. | |
| 54 | Was infant transferred within 24 hours of delivery? | |
| 55 | Is infant living at time of the report? | |
| 56 | Is infant being breastfed? | |
| 57 | Risk factors in this pregnancy | Add "Group B streptococcus culture positive" |
| 58 | Method of delivery | |
| 59 | Infections present and/or treated during this pregnancy | Add "HIV infection" and "Other: Specify" |
| 60 | Obstetric procedures | |
| 61 | Abnormal conditions of the newborn | |
| 62 | Characteristics of labor and delivery | |
| 63 | Congenital anomalies of the newborn | |
| 64 | Maternal morbidity | |
| 65 | Onset of labor | |
| Delete under item 26 "hysterotomy/hysterectomy.")) | |
| U.S. STANDARD REPORT OF FETAL DEATH | ||
| TABLE 2: Confidential Fetal Death Certificate Items |
||
| Item Number | Item Name | Difference from U.S. Standard, if any |
| 38 | Weight of fetus | |
| 39 | Obstetric estimate of gestation | |
| 40 | Plurality | |
| 41 | If not single birth - born 1st, 2nd, 3rd etc. | |
| 42 | Mother's education | Add "Specify": next to box for "8th Grade or less" |
| 43 | Mother of Hispanic origin? | |
| 44 | Mother's race | |
| 45 | Mother's occupation | Added |
| 46 | Mother's kind of business/industry | Added |
| 47 | Mother married? | |
| 48 | Mother's height | |
| 49 | Did mother get WIC food for herself during pregnancy? | |
| 50 | Mother's prepregnancy weight | |
| 51 | Mother's weight at delivery | |
| 52 | Date last normal menses began | |
| 53 | Date of first prenatal care visit | |
| 54 | Date of last prenatal care visit | |
| 55 | Total number of prenatal visits for this pregnancy | |
| 56a | Number of previous live births | |
| 56b | Date of last live birth | |
| 57a | Number of other pregnancy outcomes | |
| 57b | Date of last other pregnancy outcome | |
| 58 | Cigarette smoking before and during pregnancy | |
| 59 | Was mother transferred to higher-level care for maternal medical or fetal indications for delivery? | |
| 60 | Father's education | Added |
| 61 | Father of Hispanic origin? | Added |
| 62 | Father's race | Added |
| 63 | Father's occupation | Added |
| 64 | Father's kind of business/industry | Added |
| 65 | Risk factors in this pregnancy | |
| 66 | Method of delivery | |
| 67 | Congenital anomalies of the fetus | |
| 68 | Maternal morbidity | |
| 69 | Infections present and/or treated during this pregnancy | Add "HIV infection" and "Other: Specify" |
[Statutory Authority: Chapter 70.58 RCW. 91-20-073 (Order 196B), § 246-491-029, filed 9/26/91, effective 10/27/91. Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as § 246-491-029, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 70.58.200. 88-19-092 (Order 310), § 248-124-010, filed 9/20/88. Statutory Authority: RCW 43.20.050 and 70.58.200. 84-02-004 (Order 270), § 248-124-010, filed 12/23/83; Order, § 248-124-010, filed 9/1/67.]
[Statutory Authority: Chapter 70.58 RCW. 91-20-073 (Order 196B), § 246-491-039, filed 9/26/91, effective 10/27/91. Statutory Authority: RCW 43.20.050. 91-02-051 (Order 124B), recodified as § 246-491-039, filed 12/27/90, effective 1/31/91. Statutory Authority: RCW 70.58.200. 88-19-092 (Order 310), § 248-124-015, filed 9/20/88.]
(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 dissolution.
(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 ((and shall make
the following modifications:)). Tables 3, 4, and 5 identify the
modifications to the United States standard forms for live birth,
fetal death, and death. Tables 6 and 7 identify modifications to
the United States standard form for marriage, and certificate of
divorce, dissolution of marriage, or annulment.
| Delete "confidential information" under items 24 through 27b.)) | |
| 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" |
| 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" |
| 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 | |
[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.]