Vital Record Item | Long Form Certification of Death | Short Form Certification of Death | Informational Copy of Death |
State file number | Yes | Yes | Yes |
Date certificate issued | Yes | Yes | Yes |
Fee number | Yes | Yes | Yes |
Decedent's legal first and middle name(s) | Yes | Yes | Yes |
Decedent's last name(s) | Yes | Yes | Yes |
County of death | Yes | Yes | Yes |
Date of death | Yes | Yes | Yes |
Hour of death | Yes | Yes | Yes |
Sex | Yes | Yes | Yes |
Age | Yes | Yes | Yes |
Social Security number | Yes | No | No |
Place of death | Yes | Yes | Yes |
Facility or address of death | Yes | Yes | Yes |
City, state, zip | Yes | Yes | Yes |
Hispanic origin | Yes | Yes | Yes |
Race | Yes | Yes | Yes |
Residence street | Yes | Yes | Yes |
Residence city, state, zip | Yes | Yes | Yes |
Residence county | Yes | Yes | Yes |
Is residence inside city limits? | Yes | Yes | Yes |
Tribal reservation | Yes | Yes | Yes |
Length of time at residence | Yes | Yes | Yes |
Birth date | Yes | Yes | Yes |
Birthplace | Yes | Yes | Yes |
Father/parent name | Yes | Yes | Yes |
Mother/parent name | Yes | Yes | Yes |
Marital status | Yes | Yes | Yes |
Spouse | Yes | Yes | Yes |
Method of disposition of remains | Yes | Yes | Yes |
Place of disposition of remains | Yes | Yes | Yes |
City, state of disposition of remains | Yes | Yes | Yes |
Disposition date of remains | Yes | Yes | Yes |
Occupation | Yes | Yes | Yes |
Industry | Yes | Yes | Yes |
Education | Yes | Yes | Yes |
U.S. Armed Forces | Yes | Yes | Yes |
Informant name | Yes | Yes | Yes |
Informant's relationship to decedent | Yes | Yes | Yes |
Informant's address | Yes | Yes | Yes |
Funeral facility | Yes | Yes | Yes |
Funeral facility address | Yes | Yes | Yes |
Funeral facility city, state, zip | Yes | Yes | Yes |
Funeral director name | Yes | Yes | Yes |
Cause of death (A, B, C, and D) | Yes | No | No |
Other conditions contributing to death | Yes | No | No |
Date of injury | Yes | No | No |
Hour of injury | Yes | No | No |
Injury at work | Yes | No | No |
Place of injury | Yes | No | No |
Location of injury | Yes | No | No |
City, state, zip of injury | Yes | No | No |
County of injury | Yes | No | No |
Describe how the injury occurred | Yes | No | No |
If transportation injury, specify | Yes | No | No |
Manner of death | Yes | No | No |
Autopsy | Yes | No | No |
Were autopsy findings available to complete cause of death? | Yes | No | No |
Did tobacco use contribute to death? | Yes | No | No |
Pregnancy status if female | Yes | No | No |
Certifier name | Yes | No | No |
Certifier title | Yes | No | No |
Certifier address | Yes | No | No |
Certifier city, state, zip | Yes | No | No |
Date signed by certifier | Yes | No | No |
Case referred to ME/coroner? | Yes | No | No |
File number | Yes | No | No |
Attending physician | Yes | No | No |
Local deputy registrar | Yes | Yes | Yes |
Date received by local deputy registrar | Yes | Yes | Yes |
Vital Record Item | Certification of Fetal Death | Certification of Birth Resulting in Stillbirth |
State file number | Yes | Yes |
Date certificate issued | Yes | Yes |
First and middle name(s) of fetus | Yes | Yes |
Last name(s) of fetus | Yes | Yes |
Sex | Yes | Yes |
Date and time of delivery | Yes | Yes |
Place of delivery (city, county, state) | Yes | Yes |
Name of facility | Yes | Yes |
Mother/parent's name prior to first marriage | Yes | Yes |
Mother/parent's place of birth | Yes | Yes |
Mother/parent's date of birth or age at the time of the delivery | Yes | Yes |
Father/parent's current legal name | Yes | Yes |
Father/parent's place of birth | Yes | Yes |
Father/parent's date of birth or age at the time of the delivery | Yes | Yes |
Name and title of person completing cause of death | Yes | No |
Date signed by person completing cause of death | Yes | No |
Name and title of person delivering the fetus | Yes | No |
Method of disposition | Yes | |
Date of disposition | Yes | No |
Place of disposition | Yes | No |
Disposition location – City/town, and state | Yes | No |
Funeral facility name | Yes | No |
Funeral facility address | Yes | No |
Funeral director name | Yes | No |
Initiating cause/condition | Yes | No |
Other significant causes or conditions | Yes | No |
Estimated time of fetal death | Yes | No |
Was an autopsy performed? | Yes | No |
Was a histological placental examination performed? | Yes | No |
Local deputy registrar | Yes | No |
Data record filed | Yes | Yes |
Fee number | Yes | Yes |