Death Certificate Worksheet This form is required in order for us to process the death certificate. Please fill out the information carefully. 1Basic Information2Location3Decedent's Info4Decedent's Address5RelationshipsDecedent's Full Name(Required) First Middle Last Suffix Date of Death(Required) Address of Death Location(Required) Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Where did the death occur?HospitalHospice FacilityDecedent's HomeNursing Home/Long-term FacilityOtherFacility or Location Name (if applicable)County of Death(Required)Clark CountyCowlitz CountySkamania CountyOtherPlease list County NameDate of Birth(Required) City and State of Birth(Required)Please enter both the city and state for our records.Social Security NumberGender Male Female Non-binaryUS Veteran Yes No UnknownHighest Level of Education8th grade or less9th - 12th grade, no diplomahigh school graduate or GED completedAssociate degree (e.g. AA, AS)Bachelor's degree (e.g. BA, BS, AB)Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) )Doctorate (e.g. PhD or EdD) or professional degree (e.g. MD, DDs etc.),Race(Required)American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteWas Decedent of Hispanic Origins?NO, not Spanish/Hispanic/LatinoYes, Mexican, Mexican AmericanYes, Puerto RicanYes, CubanYes, other Spanish/Hispanic/LatinoDecedent's Address(Required) Same as Death Location Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Within City Limits?(Required) YES NOEstimated length of residence?(Required)Please specify months or yearsMarital Status(Required)MarriedMarried, but separatedWidowedDivorcedNever MarriedUnknownSpouses full MAIDEN nameIndustry of OccupationFather's Name First Middle Last Suffix Mother's Name (Maiden) First Middle Last Informant's Name First Last Relationship to DecedentInformant's Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
