09-11-111

WSR 09-11-111

PERMANENT RULES

DEPARTMENT OF HEALTH

[ Filed May 19, 2009, 5:15 p.m. , effective June 19, 2009 ]

     Effective Date of Rule: Thirty-one days after filing.

     Purpose: The change adds a form for the courts to file a record of a dissolution of a domestic partnership. The rule adds the details of the new form to the existing rule concerning vital records. This makes it consistent with the documentation of details of all other vital records forms.

     Citation of Existing Rules Affected by this Order: Amending WAC 246-491-149.

     Statutory Authority for Adoption: RCW 26.09.150.

      Adopted under notice filed as WSR 09-07-052 on March 11, 2009.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

     Date Adopted: May 19, 2009.

Mary C. Selecky

Secretary

OTS-2096.2

AMENDATORY SECTION(Amending WSR 02-20-092, filed 10/1/02, effective 11/1/02)

WAC 246-491-149   Information collected on the legal or public section of certificates; modifications to the United States standard certificates and report forms.   (1) Effective January 1, 2003, the department shall use the 2003 revisions of the United States standard forms for live birth and fetal death.

     (2) Effective January 1, 2004, the department shall use the 2003 standard form for death.

     (3) Effective January 1, 1992, the department shall use the 1988 revisions of the United States standard forms for marriage and certificate of divorce, dissolution of marriage or annulment.

     (4) These forms are developed by the United States Department of Health and Human Services, National Center for Health Statistics. Copies of these forms may be obtained by contacting the department's center for vital statistics.

     (5) With the exception of the confidential section, the department may modify any part of these forms.

     (a) Table((s)) 3((, 4, and 5 identify)) identifies the modifications to the United States standard form((s)) for live birth((, fetal death, and death)).

     (b) Table 4 identifies the modifications to the United States standard form for fetal death.

     (c) Table 5 identifies the modifications to the United States standard form for death.

     (d) Table((s)) 6 ((and 7 identify)) identifies modifications to the United States standard form for marriage((, and certificate of divorce, dissolution of marriage, or annulment)).

     (e) Table 7 identifies modifications to the United States standard form for certificate of divorce, dissolution of marriage, or annulment.

     (6) Table 8 lists items to be collected on the certificate of dissolution of Washington state domestic partnership. This is a Washington state form not addressed in the United States standard forms.

U.S. STANDARD CERTIFICATE OF LIVE BIRTH
Table 3: Legal or Public Birth Certificate Items
Item Number	Item Name	Difference from U.S. Standard, if any
1	Child's name
2	Child's date of birth
3	Time of birth
4	Type of birthplace	Add "En route," Add "Planned birthplace if different"
5	Child's sex
6	Name of facility
7	City, town or location of birth
8	County of birth
9	Mother's name before first marriage
10	Mother's date of birth
11	Mother's birthplace
12	Mother's Social Security number
13	Mother's current legal last name
14	Social Security number requested for child?
16a	Mother's residence - number, street, and Apt. No.
16b	Mother's residence - city or town
16c	Mother's residence - county
16d	Tribal reservation name (if applicable)	Added
16e	Mother's residence - state or foreign country
16f	Mother's residence - zip code + 4
16g	Mother's residence - inside city limits?
17	Telephone number	Added
18	How long at current residence?	Added
19	Mother's mailing address, if different
25	Father's current legal name
26	Father's date of birth
27	Father's birthplace
28	Father's Social Security number
66	Certifier name and title	Delete check boxes
67	Date certified
68	Attendant name and title	Delete check boxes
69	NPI of person delivering the baby
---	Date filed by registrar	Deleted

U.S. STANDARD REPORT OF FETAL DEATH
Table 4: Legal or Public Fetal Death Certificate Items
Item Number	Item Name	Difference from U.S. Standard, if any
1	Name of fetus
2	Sex
3	Date of delivery
4	Time of delivery
5	Type of birthplace	Add "En route," Add "Planned birthplace if different"
6	Name of facility
7	Facility ID (NPI)
8	City, town or location of birth
9	Zip code of delivery
10	County of birth
11	Mother's name before first marriage
12	Mother's date of birth
13	Mother's current legal last name
14	Mother's birthplace
15a	Mother's residence - number, street, and Apt. No.
15b	Mother's residence - city or town
15c	Mother's residence - county
15d	Tribal reservation name (if applicable)	Added
15e	Mother's residence - state or foreign country
15f	Mother's residence - zip code + 4
15g	Mother's residence - inside city limits?
16	How long at current residence?	Added
17	Father's current legal name
18	Father's date of birth
19	Father's birthplace
20	Name and title of person completing the report
21	Date report completed
22	Attendant name and title	Delete check boxes
23	NPI of person delivering the baby
24	Method of disposition
25	Date of disposition
26	Place of disposition	Added
27	Location of disposition - city/town and state	Added
28	Name and complete address of funeral facility	Added
29	Funeral director signature	Added
30	Initiating cause/condition (cause of death)
31	Other significant causes or conditions
32	Estimated time of fetal death
33	Was an autopsy performed?
34	Was a histological placental examination performed?
35	Were autopsy or histological placental examination results used in determining the cause of death?
36	Registrar signature	Added
37	Date received

U.S. STANDARD CERTIFICATE OF DEATH
Table 5: Death Certificate Items
Item Number	Item Name	Difference from U.S. Standard, if any
1	Legal name (include a.k.a.'s if any)
2	Death date
3	Sex
4a	Age - years
4b	Age - under 1 year
4c	Age - under 1 day
5	Social Security number
6	County of death
7	Birth date
8a	Birth place - city, town or county
8b	Birth place - state or foreign country
9	Decedent's education	Add "Specify": next to box for "8th Grade or less"
10	Decedent's Hispanic origin
11	Decedent's race
12	Was decedent ever in U.S. Armed Forces?
13a	Residence - number and street
13b	Residence - city or town
13c	Residence - county
13d	Tribal reservation name (if applicable)	Added
13e	Residence - state or foreign country
13f	Residence - zip code
13g	Inside city limits?
14	Estimated length of time at residence	Added
15	Marital status at time of death
16	Surviving spouse's name
17	Occupation
18	Kind of business/industry
19	Father's name
20	Mother's name before first marriage
21	Informant - name
22	Informant - relationship to decedent
23	Informant - address
24	Place of death
25	Facility name (if not a facility, give number and street)
26a	City, town, or location of death
26b	State of death
27	Zip code of death
28	Method of disposition
29	Place of disposition (name of cemetery, crematory, other place)
30	Disposition - city/town, and state
31	Name and complete address of funeral facility
32	Date of disposition	Added
33	Funeral director signature
34	Causes of death and intervals between onset and death
35	Other significant conditions contributing to death
36	Autopsy?
37	Were autopsy findings available to complete the cause of death?
38	Manner of death
39	Pregnancy status
40	Did tobacco use contribute to death?
41	Date of injury
42	Hour of injury
43	Place of injury
44	Injury at work?
45	Injury location - street, city, county, state, zip	County Added
46	Describe how injury occurred
47	Transport injury type
48a	Certifying physician signature
48b	Medical examiner/coroner signature
49	Name and address of certifier
50	Hour of death
51	Name and title of attending physician if other than certifier	Added
52	Date certified
53	Title of certifier
54	License number of certifier
55	ME/coroner file number	Added
56	Was case referred to medical examiner?
57	County registrar signature	Added
58	County date received	Added
59	Record amendment	Added
--	License number of funeral director	Deleted
--	Date pronounced dead	Deleted
--	Time pronounced dead	Deleted
--	Signature of person pronouncing death	Deleted
--	License number of person pronouncing death	Deleted
--	Date person pronouncing death signed	Deleted

U.S. STANDARD LICENSE AND CERTIFICATE OF MARRIAGE
Table 6: Certificate of Marriage
Item Number	Item Name	Difference from U.S. Standard, if any
--	Certificate name	Changed name of form to "Certificate of Marriage”
--	County of license
--	Date valid
--	Not valid after (date)
1	Date of marriage
2	County of ceremony
3	Type of ceremony	Added
4	Date signed (by officiant)	Added
5	Officiant's name
6	Officiant's signature
7	Officiant's address
8	Groom's name
9	Groom's address (street)
10	Groom's date of birth
11	Groom's place of birth (state or country)
12	Groom's address (city)
13	Groom's address (inside city limits)	Added
14	Groom's address (county)
15	Groom's address (state)
16	Groom's father - name
17	Groom's father - place of birth
18	Groom's mother - maiden name
19	Groom's mother - place of birth
20	Groom's signature
21	Date signed (by groom)
22	Bride's name
23	Bride's maiden last name
24	Bride's residence - (street)
25	Bride's date of birth
26	Bride's place of birth (state or country)
27	Bride's residence (city)
28	Bride's residence (inside city limits)	Added
29	Bride's residence (county)
30	Bride's residence (state)
31	Bride's father - name
32	Bride's father - place of birth
33	Bride's mother - maiden name
34	Bride's mother - place of birth
35	Bride's signature
36	Date signed (by bride)
37	Witness #1 signature
38	Witness #2 signature
39	County auditor signature
40	Date received (by county auditor)
Reverse side		Groom's Social Security number
Reverse side		Bride's Social Security number
	Groom's age last birthday	Deleted
	Bride's age last birthday	Deleted
	License to marry section	Deleted
	Expiration date of license	Deleted
	Title of issuing official	Deleted
	Confidential information	Deleted

U.S. STANDARD CERTIFICATE OF DIVORCE, DISSOLUTION OF MARRIAGE, OR ANNULMENT
TABLE 7: Certification of Dissolution, Declaration of Invalidity of Marriage, or Legal Separation
Item Number	Item Name	Difference from U.S. Standard, if any
	Certificate name	Changed form name to certificate of dissolution, declaration of invalidity of marriage or legal separation
	Court file number
1	Type of decree	Added check boxes
2	Date of filing
3	County where decree filed
4	Signature of superior court clerk
5	Husband's name
6	Husband's date of birth
7	Husband's place of birth
8	Husband's residence - street
9	Husband's residence - city
10	Husband's residence - inside city limits	Added
11	Husband's residence - county
12	Husband's residence - state
13	Wife's name
14	Wife's maiden name
15	Wife's date of birth
16	Wife's place of birth
17	Wife's residence - street
18	Wife's residence - city
19	Wife's residence - inside city limits	Added
20	Wife's residence - county
21	Wife's residence - state
22	Place of marriage - county
23	Place of marriage - state
24	Date of marriage
25	Number of children of this marriage	Name change
26	Petitioner	Delete check boxes
27	Name of petitioner's attorney/pro se
28	Petitioner's address
29	Husband's Social Security number
30	Wife's Social Security number
	Date couple last resided in same household	Delete
	Number of children under 18 whose physical custody was awarded to	Delete
	Title of court	Delete
	Title of certifying official	Delete
	Date signed	Delete
	Confidential information	Delete

TABLE 8: Certification of Dissolution of Washington State Domestic Partnership
Item Number	Item Name
	Certificate name
	Court file number
1	Type of decree
2	Date of decree
3	County where decree filed
4	Signature of superior court clerk
5a	First partner's name
5b	First partner's name at birth
6	First partner's date of birth
7	First partner's place of birth
8	First partner's residence - street
9	First partner's residence - city
10	First partner's residence - inside city limits
11	First partner's residence - county
12	First partner's residence - state
13a	Second partner's name
13b	Second partner's name at birth
14	Second partner's date of birth
15	Second partner's place of birth
16	Second partner's residence - street
17	Second partner's residence - city
18	Second partner's residence - inside city limits
19	Second partner's residence - county
20	Second partner's residence - state
21	Date of this partnership
22	Domestic partnership certificate number
23	Petitioner
24	Name of petitioner's attorney/pro se
25	Petitioner's address

[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.]