Wash. Admin. Code § 246-491-149
Current through Register Vol. 24-19, October 1, 2024
The department shall collect the following items on the legal or public section of reports for registration into the statewide vital records system in accordance with chapter 70.58A RCW and this section.
REPORT OF LIVE BIRTH
Table 3: Legal or Public Birth Record Items
| Item Name | Difference fromU.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. | |
| 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 |
REPORT OF FETAL DEATH
Table 4: Legal or Public Fetal Death Record Items
| 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. | |
| 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 histo-logical placental examination results used in determining the cause of death? | |
| Registrar signature | Added |
| Date received |
REPORT OF DEATH
Table 5: Death Record Items
| Item Name | Difference from U.S. Standard, if any |
| Legal name (include a.k.a. if any) | |
| Death date | |
| Sex | Add "X" as non-binary 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 | |
| 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 | |
| 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, | County Added |
| city, county, state, zip | |
| 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 |
REPORT OF MARRIAGE
Table 6: Certification of Marriage
| Item Name | Difference fromU.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 | 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 |
REPORT OF DIVORCE, DISSOLUTION OF MARRIAGE, OR ANNULMENT
Table 7:
Certification of Dissolution, Declaration of Invalidity of Marriage, or Legal Separation
| 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 | |
| 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 |
Table 8: Certification of Dissolution of Washington State Domestic Partnership
| 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 |
Wash. Admin. Code § 246-491-149
Statutory Authority: RCW 43.70.150. 13-01-004, § 246-491-149, filed 12/6/12, effective 12/6/12. Statutory Authority: RCW 26.09.150. 09-11-111, § 246-491-149, filed 5/19/09, effective 6/19/09. 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.