Death Record Form - Utah Vital Records Page 6
Download a blank fillable Death Record Form - Utah Vital Records in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Death Record Form - Utah Vital Records with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6Death Record Form
Page 4 of 4
27. Method of Disposition
Burial
Removal from State
Other (Specify) _________________________
Cremation
Entombment
Donation
28. Date of Disposition
______________________________ ______, ____________
Month
Day
Year
29. Place of Disposition (Name of Cemetery, Crematory or Other Place)
_____________________________________________________________________________________________________________
30. Location of Disposition
___________________________________________ ___________________________________________ ____________________
State
City
Zip
Certifying Physician Information:
31. Name of Certifying Physician
_____________________________________________________________________________________________________________
First
_____________________________________________________________________________________________________________
Middle
___________________________________________________________________________________________ ________________
Last
Suffix
_____________________________________________________________________________________________________________
Physician’s Address (PO BOX should not be used)
___________________________________________ ___________________________________________ ____________________
State
City
Zip
Phone Number
: _________ - _________ - ____________
32. Was the Medical Examiner Contacted?
Yes
No z
Unknown
M.E. Case Number
Date
________________________________________________
___________________________________
I hereby certify that the information provided above is true and accurate to the best of my personal
knowledge.
I further understand that any person who intentionally signs the portion of a certificate of death that is
required to be signed by a funeral service director or dispositioner is guilty of a class B misdemeanor,
unless the person:
(a) (i) is a funeral service director; and
(ii) is employed by a licensed funeral establishment; or
(b) is a dispositioner, if a funeral service director is not retained.
Utah Code 26-2-16 (5)
Dispositioner’s Signature:
________________________________________________________________________________
Date:
______________________________________________________________________________________________________
Local Health Office Use Only:
Local or State Registrar’s Signature:
_____________________________________________________________________
Date:
______________________________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal