Death Record Form - Utah Vital Records
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6Death Record Form Instructions
(For Dispositioners – Download a printable copy)
UDOH ovrs0146 revision 08172015
1 – Decedent’s Legal Name
Enter the first, middle and last name of the person whose death is being reported.
Suffix – Enter the suffix of the person whose death is being reported. (e.g. Jr., Sr., I, II, III, etc.) if applicable.
2 – Sex
Enter Male or female.
3 – Date of Death (Month, Day, Year)
Enter the exact number of the month, day and year that the death occurred.
A death that occurs around midnight (2400 hours) should be considered to have occurred at the end of the day rather than the
beginning of the next.
For instance, the date for a death that occurs at midnight on December 31 should be recorded as December 31.
4 – City/Town of Death
Enter the name of the city, town or location where the death occurred.
5 – County of Death
Enter the name of the county where death occurred
6 – Date of Birth
Enter the exact number of the month, day, and year that the decedent was born.
7 – Social Security Number
Enter the social security number of the decedent.
8 – AKA
If the deceased person had an alias, it should be preceded with A.K.A. (Also Known As).
If decedents name is substantially different from the legal name, enter AKA.
For example, Samuel Langhorne Clemens AKA Mark Twain.
Nicknames are not considered an alias.
9- Age
Enter the decedent’s exact age in years at his or hers last birthday.
If decedent was under 1 year:
If the infant as between one and eleven months, give the age in completed months.
If decedent was under 1 day:
If the infant was between one and twenty-three hours, list the age in hours. If the infant was less than one hour, give the age in
minutes.
10 – Decedent’s Place of Birth
If the decedent was born in the United States or Canada, enter the name of the State or Canadian Province of birth.
If the decedent was not born in the United States or Canada, enter the name of the country of birth whether or not the decedent
was a citizen at the time of death.
11. – Was the Decedent Ever in the Armed Forces
If the decedent was ever in the U.S. Armed Forces, check “Yes”, if not, check “No” or “Unknown”.
12 – Marital Status
Check the appropriate box to indicate the marital status of the deceased at the time of death.
If the deceased had filed for divorce, but is not yet final, the marital status should be marked as “Married.
13 - Surviving Spouse’s Name
If the decedent was married at the time of death, enter the full name of the surviving spouse (Prior to first marriage).
If the decedent was divorced, widowed, or never married, leave this item blank.
14 - Occupation
Questions concerning occupation and industry must be completed for all decedents 14 years of age or older.
Give the kind of work done during most of working life. DO NOT enter Retired.
Enter the usual occupation of the decedent. “Usual Occupation” is the kind of work the decedent did during most of his or her
working life such as: Claim Adjuster, Farmhand, Coal Miner, Janitor, Store Manager, College Professor.
If the decedent was a homemaker at the time of death but had worked outside the household during his or her working life, enter
that occupation.
If the decedent was a homemaker during most of his or her working life, and never worked outside the household, enter
“Homemaker”.
Enter “Student” if the decedent was a student at the time of death and was never regularly employed or employed full time during
his or her working life.
15 - Kind of Business/Industry
Enter the kind of business or industry to which the occupation listed above is related, such as: Insurance, Farming, Coal Mining,
Hardware Store, Retail Clothing, University. DO NOT enter firm or organization name.
If the decedent was a homemaker during his or her working life and “Homemaker” is entered as the decedent’s occupation above,
enter “Own Home”.
If the decedent was a student at the time of death and “Student” is entered as decedent’s usual occupation above, enter the type
of school, such as: “High School” or “College”.
Continued…
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