Vital Statistics Form printable pdf download

Tumwater – 455 North St SE, Tumwater, WA 98501

360-753-1065 Fax 360-357-6711

VITAL STATISTICS

Lacey – 2830 Willamette Dr NE Ste G, Lacey, WA 98516

360-491-2222 Fax 360-491-9210

FORM

Centralia – 1126 S Gold St Ste 208, Centralia, WA 98531

360-807-4468 Fax 360-807-4591

To complete the Death Certificate

E-mail:

Website:

Legal Name (Include AKA’s if any)

First

Middle

Last

Check One  Male  Female

Social Security Number

Birthdate

Birthplace

City, County, State, Foreign Country

Level of Education

 8th grade or less (Specify)

 9th - 12th grade; no diploma

 High school graduate or GED completed

 Some college credit, but no degree

 Associate degree (e.g., AA, AS)

 Bachelor’s degree (e.g., BA, AB, BS )

 Master’s degree (e.g., MA, MS, M Eng, M Ed, MSW, MBA)

 Doctorate (e.g., PhD, Ed D) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

Hispanic Origin or Descent? (If Spanish/Hispanic/Latino Origin/Descent, check the box of best description)

 No, not Spanish/Hispanic/Latino

 Yes, Cuban

 Yes, Mexican, Mexican American, Chicano

 Yes, other Spanish/Hispanic/Latino

 Yes, Puerto Rican

(Specify)

Race (Check one or more to indicate what you consider the race to be)

 White  Black or African American  American Indian/Alaska Native (Tribe)

 Asian Indian  Chinese  Filipino  Japanese  Korean  Vietnamese  Other Asian

 Native Hawaiian  Guamanian or Chamorro  Samoan  Other Pacific Islander (specify)

 Other (specify):

Served in U.S. Armed Forces?  Yes  No

If Yes, provide copy of DD214 (Discharge papers)

Usual Occupation

Kind of Business or Industry

(Indicate type of work done during most of working life, DO NOT USE RETIRED)

Residence Number and Street

City or Town

County

State

Zip Code

Tribal Reservation Name (if applicable)

Inside City Limits  Yes  No  Unknown

Estimated time at residence

Marital Status  Married  Married-but separated  Widowed  Divorced  Never married

 State Registered Domestic Partner  Unknown

Surviving Spouse name

Give name prior to first marriage

Father’s Name

Mother’s Name

(of deceased)

First, Middle, Last, Suffix

(of deceased)

First, Middle, Last name before first marriage

Informant’s Name

Relationship to Decedent

Mailing Address

Number and Street or Post Office Box, City or Town, State, Zip Code

Phone number(s)

Email Address

Primary Care Physician

Phone

5/5/2014

Vital Statistics Form

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