(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 3 identifies the modifications to the United States standard form for live birth.

(b) Table 4 identifies the modifications to the United States standard form for fetal death.

(d) Table 6 identifies modifications to the United States standard form for marriage.

(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.

(7) Modification to the United States standard form for marriage for parties who previously had a state-registered domestic partnership. Parties who previously had a state-registered domestic partnership and become married in Washington may obtain an amended marriage certificate from the state registrar that includes the legal date of marriage. Marriage certificates issued to parties who have a state-registered domestic partnership and who are deemed married under RCW 26.60.100 shall include the legal date of marriage of the parties. The legal date of marriage is defined in RCW 26.60.100(4) as the date of the original state-registered domestic partnership.

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. 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	Modified
1	County of license	Added
2	Date valid
3	Not valid after (date)
4	County auditor signature
5	Date received (by county auditor)
6a	Person A - Bride/groom/spouse	Added
6b	Legal name before marriage	Modified
6c	Birth name, if different	Added
6d	Sex - Male/female	Added
6e	Current residence (street, city/town)
6f	County of residence
6g	State of residence
6h	Date of birth
6i	Birth state (if not USA, provide country)
6j	Mother/parent birth name	Modified
6k	Father/parent birth name	Modified
6l	Mother/parent birth state (or country)	Modified
6m	Father/parent birth state (or country)	Modified
7a	Person B - Bride/groom/spouse	Added
7b	Legal name before marriage
7c	Birth name, if different	Modified
7d	Sex - Male/female	Added
7e	Current residence (street, city/town)
7f	County of residence
7g	State of residence
7h	Date of birth
7i	Birth state (if not USA, provide country)
7j	Mother/parent birth name	Modified
7k	Father/parent birth name	Modified
7l	Mother/parent birth state (or country)	Modified
7m	Father/parent birth state (or country)	Modified
8	Date of marriage
9	County of ceremony
10	Type of ceremony	Added
11	Date signed (by officiant)	Added
12	Officiant's address
13	Officiant's daytime phone	Added
14	Officiant's name
15	Officiant's signature
16	Witness signature
17	Witness signature
18	Person A signature	Modified
19	Date signed (by person A)	Added
20	Person B signature	Modified
21	Date signed (by person B)	Added
22	Person A - Social Security number	Added
23	Person A - Name	Added
24	Person B - Social Security number	Added
25	Person B - Name	Added
26	Person A signature - Declaration in absence of a Social Security number	Added
27	Person A date - Declaration in absence of a Social Security number	Added
28	Person B signature - Declaration in absence of a Social Security number	Added
29	Person B date - Declaration in absence of a Social Security number	Added
	(Groom's) age last birthday	Deleted
	(Bride's) age last birthday	Deleted
	Signature of (license) issuing official	Deleted
	Title of (license) issuing official	Deleted
	Where married - City, town or location	Deleted
	Title (of officiant)	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	Modified
1	Court file number	Added
2	Type of decree
3	Date of decree
4	County where decree filed
5	Signature of superior court clerk
6a	Spouse A - Name	Added
6b	Birth name, if different	Added
6c	Date of birth
6d	Place of birth (state or country)
6e	Residence - Street	Added
6f	Residence - City
6g	Residence - County
6h	Residence - State
7a	Spouse B - Name	Added
7b	Birth name, if different	Modify
7c	Date of birth
7d	Place of birth (state or country)
7e	Residence - Street	Added
7f	Residence - City
7g	Residence - County
7h	Residence - State
8	Place of marriage -County
9	Place of marriage - State
10	Date of marriage
11	Number of children born alive of this marriage	Added
12	Petitioner
13	Name of petitioner's attorney or pro se
14	Petitioner's attorney's address
15	Spouse A Social Security number	Added
16	Spouse B Social Security number	Added
	Date (decree) recorded	Deleted
	Number of children under 18 whose physical custody was awarded to (husband, wife, joint, other)	Deleted
	Number of children under 18 in household	Deleted
	Title of court	Deleted
	Title of certifying official	Deleted
	Date (certifying official) signed	Deleted
	Date couple last resided in same household	Deleted
	Confidential items	Deleted

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

PDFWAC 246-491-149

Information collected on the legal or public section of certificates; modifications to the United States standard certificates and report forms.