Death Record Form - Utah Vital Records Page 2
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6Death Record Form Instructions
Page 2 of 2
16 - Residence of Decedent
The residence of the decedent is the place where his or her household is located.
The street address, apartment number, state, city, county and zip code should be for the place where the decedent actually lived
most of the time.
A PO Box should Not be entered.
If the decedent was not a resident of the United States, enter the name of the country.
Mark “Yes” in Inside City Limits, if decedent’s residence is believed to be within the city or community limits or boundaries,
otherwise, mark “No” or “Unknown”.
17 - Parent’s Name or Father Prior to First Marriage
Enter the first, middle, last name and suffix of the parent or father of the decedent.
18 - Parent’s Name or Mother Prior to First Marriage
Enter the first, middle, last name and suffix of the parent or mother of the decedent
19 - Name, Relationship and Mailing Address of Informant
Enter the first, middle, last name and suffix of the person who supplied the personal facts about the decedent and his or her
family.
Enter the relationship to decedent.
Enter complete mailing address of the informant.
21 - Decedents Race
Check the race of the decedent. For American Indians, enter name of principal tribe.
For Asians and Pacific Islanders, check the box indicating the national origin of the decedent.
If the decedent was of mixed race, multiple races may be checked.
22 - Decedents Education
Check the highest number of years of regular schooling completed by the decedent.
Check only those years of school completed.
23 - Time of Death
Enter the exact time of death as recorded by the 24-hour clock.
24 - Date Deceased Was Last Attended By Certifying Physician or Agent
Enter the month, day, and year that the decedent was last attended by the certifying physician.
Dates attended by Home Health Care Givers, Physicians Assistants, Hospice Personnel, etc. are acceptable last attended dates
and if within 30 days of the date of death do not need to be reported to the Medical Examiner.
25 - Place of Death
The place where the death is pronounced should be considered the place where death occurred.
If the decedent died at a hospital, the patient status should be indicated.
If the decedent was an admitted patient at the hospital, check “Inpatient”.
If the decedent as alive in the Emergency Room or Outpatient Clinic check “ER/Outpatient”.
If the decedent was determined to be Dead on Arrival at the hospital, check Dead on Arrival.
If the Death occurred in a hospital, enter the name of the hospital.
If the decedent was determined to be DOA at the location where ambulance or other vehicle picked up the body, DO NOT check
DOA. In this case check the Other box and specify.
26 - Death Occurred Somewhere Other Than A Hospital
If the death occurred in a Nursing Home or Care Facility, check appropriate box.
If the death occurred at the decedents home, check appropriate box.
If the death occurred at some other residence in Utah indicate in other/specify.
Facility Name - If the death occurred at decedents home you may enter house number and street name/number.
If the death occurred outside a facility, enter the number and street name of the place, or a description of a rural area.
27 - Method of Disposition
Check the corresponding box to the method of disposition of the decedent’s body.
28 - Date of Disposition
Enter the exact number of the month, day and year of burial or other disposition of the decedent.
29- Place of Disposition
Enter the name of the cemetery, crematory, or other place of disposition.
30 - Location of Disposition
Enter the state and city where the place of disposition is located.
31 - Name of Physician Certifying Death
Enter the name, address and phone number of the physician responsible for completing and certifying cause of death.
32 - Was the Medical Examiner Contacted?
If the death was reported to the Medical Examiner’s Office. Enter “Yes”, “No” or “Unknown”. If “Yes” enter the full ME Case
Number given and date.
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