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. No. | |
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 |
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. No. | |
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 histological placental examination results used in determining the cause of death? | |
Registrar signature | Added |
Date received |
Item Name | Difference from U.S. Standard, if any |
Legal name (include a.k.a. if any) | |
Death date | |
Sex | Add "X" as nonbinary 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 origin | |
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 death | |
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, city, county, state, zip | County Added |
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 |
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 name | 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 |
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 filed | |
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 |
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 |