WASHINGTON STATE DEATH WORKSHEET Legal Name (Include AKA's if any) Death Date01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Sex Age - Last Birthday Under 1 Year Under 1 Day Social Security # Was Decendent ever in the U.S. Armed Forces?YesNoUnknown Birthdate Birthplace State or Foreign Country Decedent's Education (Check the box that best describes the highest degree or level of school completed at hte time of death.)8th grade or less 9th-12th grade; no diplomaHigh school graduate or GED completedSome college credit, but no degreeAssociate degree (e.g. AA, AS)Bachelor's degree (e.g., BA, AB, BS)Master's degree (e.g., MA, MS, MEng, MEd, MSW, MBA)Doctorate (e.g., PhD EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD) Was Decedent of Hispanic Origin? (Check the box that best describes whether the decedent was Spanish/Hispanic/Latino or check the "no" box if decedent was not Spanish/Hispanic/Latino.)No, not Spanish/Hispanic/LatinoYes, Mexican, Mexican American, ChicanoYes, Puerto RicanYes, CubanYes, other Spanish/Hispanic/Latino* * (Specify) Decedent's Race (Check one or more races to indicate what the decedent considered himself or herself to be.)WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsian Indian*ChineseFilipinoJapaneseKoreanVietnameseOther AsianNative Hawaiian*Guamanian or ChamorroSamoanOther Pacific IslanderOther* * Specify Residence: Number and Street (e.g., 624 SE 5th St.,) (Include Apt. No.) City or Town Residence: County Tribal Reservation Name (if applicable) State or Foreign Country Zip Code +4 Inside City Limits?YesNoUnknown Estimated length of time at residence. (Specify unites (e.g. 6 years, 6 month, etc.)) Marital Status at Time of DeathMarriedMarried, but separatedWidowedDivorcedNever MarriedUnknown Surviving Spouse's Name (Give name prior to first marriage) Ususal Occupation (Indicate type of work done during most of working life. (DO NOT USE RETIRED). Kind of Business/Industry (Do not use Company Name)Parents' & Informant's Information Father's Name Mother's Name Before First Marriage Informant's Name Relationship to Decedent Mailing Address Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Brazzaville)Costa RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWalesYemenZambiaZimbabwe CountryPlace of Death If Death Occured in a HospitalInpatientEmergency Room/OutpatientDead on Arrival If Death Occurered Somewhere Other than a HospitalHospice FacilityNursing Home/Long Term Care FacilityDecedent's HomeOther* * Specify Facility Name (if not a facility, give number & street) City, Town, or Location of Death State Zip CodeDisposition Method of DispositionBurialCremationRemoval from StateDonationEntombmentBody not RecoveredOther* * Specify Place of Disposition (Name of cemetery, crematory, other place) Location-City/Town, and State Name and Complete Address of Funeral Facility Date of Disposition Funeral Director Signature XSubmitReset
