WSR 09-11-111

PERMANENT RULES

DEPARTMENT OF HEALTH


[ Filed May 19, 2009, 5:15 p.m. , effective June 19, 2009 ]


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Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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.]

Washington State Code Reviser's Office