Items on birth and death certifications and informational copies.
Certifications and informational copies of birth and death records issued from the state vital records system must contain only items in accordance with this section.
(1) Unless the items are not available or were not collected at the time of birth registration, certifications of birth, certifications of delayed birth, and informational copies of birth and delayed births will display only the following items:
Vital Record Item | Certification of Birth and Informational Birth Copy | Certification of Delayed Birth and Informational Delayed Birth Copy |
State file number | Yes | Yes |
Date certificate issued | Yes | Yes |
First and middle name(s) of subject of the record | Yes | Yes |
Last name(s) of subject of the record | Yes | Yes |
Date of birth of subject of the record | Yes | Yes |
Facility born | Yes | Yes |
Place of birth (city, county, state) | Yes | Yes |
Time of birth | Yes | Yes |
Sex | Yes | Yes |
Mother/parent's name prior to first marriage | Yes | Yes |
Mother/parent's place of birth | Yes | Yes |
Mother/parent's date of birth or age at the time of child's birth | Yes | Yes |
Father/parent's current legal name | Yes | Yes |
Father/parent's place of birth | Yes | Yes |
Father/parent's date of birth or age at the time of child's birth | Yes | Yes |
| No | Yes |
Date record filed | Yes | Yes |
Fee number | Yes | Yes |
Signature of applicant | No | Yes |
(2)(a) For deaths registered starting January 1, 2018, long form certifications of death, short form certifications of death, and informational copies of death will display only the following items:
Vital Record Item | Long Form Certification of Death | Short Form Certification of Death | Informational Copy of Death |
State file number | Yes | Yes | Yes |
Date certificate issued | Yes | Yes | Yes |
Fee number | Yes | Yes | Yes |
Decedent's legal first and middle name(s) | Yes | Yes | Yes |
Decedent's last name(s) | Yes | Yes | Yes |
County of death | Yes | Yes | Yes |
Date of death | Yes | Yes | Yes |
Hour of death | Yes | Yes | Yes |
Sex | Yes | Yes | Yes |
Age | Yes | Yes | Yes |
Social Security number | Yes | No | No |
Place of death | Yes | Yes | Yes |
Facility or address of death | Yes | Yes | Yes |
City, state, zip | Yes | Yes | Yes |
Hispanic origin | Yes | Yes | Yes |
Race | Yes | Yes | Yes |
Residence street | Yes | Yes | Yes |
Residence city, state, zip | Yes | Yes | Yes |
Residence county | Yes | Yes | Yes |
Is residence inside city limits? | Yes | Yes | Yes |
Tribal reservation | Yes | Yes | Yes |
Length of time at residence | Yes | Yes | Yes |
Birth date | Yes | Yes | Yes |
Birthplace | Yes | Yes | Yes |
Father/parent name | Yes | Yes | Yes |
Mother/parent name | Yes | Yes | Yes |
Martial status | Yes | Yes | Yes |
Spouse | Yes | Yes | Yes |
Method of disposition of remains | Yes | Yes | Yes |
Place of disposition of remains | Yes | Yes | Yes |
City, state of disposition of remains | Yes | Yes | Yes |
Disposition date of remains | Yes | Yes | Yes |
Occupation | Yes | Yes | Yes |
Industry | Yes | Yes | Yes |
Education | Yes | Yes | Yes |
U.S. Armed Forces | Yes | Yes | Yes |
Informant name | Yes | Yes | Yes |
Informant's relationship to decedent | Yes | Yes | Yes |
Informant's address | Yes | Yes | Yes |
Funeral facility | Yes | Yes | Yes |
Funeral facility address | Yes | Yes | Yes |
Funeral facility city, state, zip | Yes | Yes | Yes |
Funeral director name | Yes | Yes | Yes |
Cause of death (A, B, C, and D) | Yes | No | No |
Other conditions contributing to death | Yes | No | No |
Date of injury | Yes | No | No |
Hour of injury | Yes | No | No |
Injury at work | Yes | No | No |
Place of injury | Yes | No | No |
Location of injury | Yes | No | No |
City, state, zip of injury | Yes | No | No |
County of injury | Yes | No | No |
Describe how the injury occurred | Yes | No | No |
If transportation injury, specify | Yes | No | No |
Manner of death | Yes | No | No |
Autopsy | Yes | No | No |
Were autopsy findings available to complete cause of death? | Yes | No | No |
Did tobacco use contribute to death? | Yes | No | No |
Pregnancy status if female | Yes | No | No |
Certifier name | Yes | No | No |
Certifier title | Yes | No | No |
Certifier address | Yes | No | No |
Certifier city, state, zip | Yes | No | No |
Date signed by certifier | Yes | No | No |
Case referred to ME/coroner? | Yes | No | No |
File number | Yes | No | No |
Attending physician | Yes | No | No |
Local deputy registrar | Yes | Yes | Yes |
Date received by local deputy registrar | Yes | Yes | Yes |
(b) For deaths registered before January 1, 2018, long form certifications of death will contain only the vital record items as indicated for long form certification in (a) of this subsection if such vital record items are available or were collected at the time of death registration.
(c) For deaths registered before January 1, 2018, informational copies of death will contain only the vital record items as indicated for informational death copy in (a) of this subsection if such vital record items are available or were collected at the time of death registration.
(d) The short form certification of death is not available for deaths registered before January 1, 2018.
(3) Certification of fetal death will display only the following items:
Vital Record Item |
Local file number |
State file number |
Name of fetus (first, middle, last, suffix) |
Sex |
Date of delivery |
Time of delivery |
Type of birthplace |
Planned birthplace, if different |
Name of facility |
Facility I.D. |
City, town, or location of delivery |
Zip code of delivery |
County of delivery |
Mother's name before first marriage (first, middle, last) |
Mother's date of birth |
Mother's current legal last name, if different |
Mother's birthplace (state, territory, or foreign country) |
Mother's residence - Number and street |
Mother's residence - Apt no. |
Mother's residence - City or town |
Mother's residence - County |
If you live on tribal reservation, give name |
State or foreign country |
Zip code +4 |
Mother's residence inside city limits |
How long at current residence? |
Name and title of person completing cause of death |
Signature of person completing cause of death |
Date signed by person completing cause of death |
Name and title of person delivering the fetus |
NPI of person delivering the fetus |
Method of disposition |
Date of disposition |
Place of disposition |
Disposition location - City/town, and state |
Name and complete address of funeral facility |
Funeral director signature |
Initiating cause/condition |
Other significant causes or conditions |
Estimated time of fetal death |
Was an autopsy performed? |
Was a histological placental examination performed? |
Registrar signature |
Date received by local registrar |
[Statutory Authority: 2019 c 148. WSR 20-13-017, § 246-491-159, filed 6/5/20, effective 1/1/21.]
