Vital Information Worksheet

1Required Information

About My Loved One

If you're unsure of an exact answer, leave it blank — we'll help with the rest.

First Name Middle Name Last Name Suffix

Sex — as recorded on the death certificate

Male Female Unknown X (non-binary)

Sex at birth — only if different from above. Social Security matches its own record, so telling us both avoids a delay.

Male Female

Date of Birth Social Security Number

Aliases — other names they were known by

First AKA Second AKA Third AKA

2Required on the Certificate

Ethnicity & Race

Choose whatever your loved one identified with — all that apply.

Hispanic Ethnicity

No, not Spanish / Hispanic / Latino Mexican / Mexican American / Chicano Puerto Rican Cuban Other

Race — choose all that apply

White Japanese Native Hawaiian Black or African American Korean Guamanian or Chamorro American Indian / Alaska Native Vietnamese Samoan Asian Indian Chinese Other Pacific Islander Filipino Other Asian Other

3Birthplace & Residence

Where They Were Born & Lived

Your loved one's birthplace and most recent home.

Place of Birth

City County State Country

Current Address — most recent residence, not birthplace

Street Unit City State Zip

Length of Time at This Address

Inside City Limits?

YesNo

Tribal Reservation?

YesNo

Did they experience homelessness at the time of, or in the month before, death? — a required question that Washington State collects for its records; it does not appear on the death certificate itself

Yes Probably No Unknown

4Education, Work & Status

Their Education & Work

Please give their usual occupation — not “retired.”

Highest Level of Education

8th grade or less 9th–12th, no diploma High school diploma or GED Some college, no degree Associate degree Bachelor's degree Master's degree Doctorate / professional degree

Usual Occupation (not “retired”) Kind of Business / Industry

U.S. Armed Forces?

YesNo

Marital Status at Time of Death

Surviving Spouse or Domestic Partner Name

5Parents

Their Parents

Including their mother's name before she first married.

Father — First Name Middle Name Suffix

Mother — First Name Middle Name Last Name (before first marriage)

6My Wishes

Service & Celebration

Where I would like my service or celebration of life to be held.

Preferred Location

Funeral Home Place of Worship Outside Venue Other

Address of venue, place of worship, or other location

6Contact

About You (the Informant)

So we know who to reach with any questions.

Your Name Relationship

Address

Phone Email

Vital Information About My Loved One

About My Loved One

Ethnicity & Race

Where They Were Born & Lived

Their Education & Work

Their Parents

Service & Celebration

About You (the Informant)