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Washington State Death Worksheet
Affordable Cremation and Burials in Snohomish, King, Skagit, Island counties and greater Puget Sound.
24-Hour service at
360-651-9233
or
800-398-7101
Decedents Legal Name (Include AKA's if any)
Death Date
Gender
- Select -
Male
Female
Age-Last Birthday
Last Birthday
Under 1 Year - For Infants Only
Under 1 Day - For Infants Only
County of Death
Birthdate
Birthplace
(City, Town, or County)
(State or Foreign Country)
Decedent's Education
- Select -
8th grade or less (highest grade completed)
9th - 12th grade; no diploma
High school gradute or GED completed
Some college credit, but no degree
Associate degree (e.g., AA, AS)
Bachelor's degree(e.g., BA, AB, BS)
Master's degree(e.g., MAMS, MEng, MEd, MSW, MBA)
Doctorate
Was Decedent of Hispanic Origin?
- Select -
No, not Spanish/Hispanic/Latino
Yes, Mexican, Mexican American,Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spanish/Hispanic/Latino
Decedent's Race
- Select -
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Somoan
Other Pacific Islander
Other
Was Decedent ever in U.S. Armed Forces?
- Select -
Yes
No
Unknown
Residence:
Number and Street (e.g., 624 SE 5th St.) (Include Apt. No.)
City or Town
County
Tribal Reservation Name (if applicable)
State or Foreign Country
Zip Code
Inside City Limits?
- Select -
Yes
No
Unknown
Estimated length of time at residence.
Marital Status at Time of Death
- Select -
Married
Divorced
Married, but separated
Never Married
Widowed
Unknown
Surviving Spouse's Name(Give name prior to first marriage)
Usual 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 (First, Middle, Last, Suffix)
Mother's Name Before First Marriage (First, Middle, Last)
Informant's Name
Relationship to Decedent
Informant's Phone Number
Informant's Email Address
Mailing Address Number and Street
City or Town
State
Zip Code
Place of Death
If Death Occurred in a Hospital
- Select -
Not Applicable
Inpatient
Emergency Room/Outpatient
Dead on Arrival
If Death Occurred Somewhere Other than a Hospital
- Select -
Hospice Facility
Decedent's Home
Nursing Home/Long Term Care Facility
Other
Informants Signature (I declare the foregoing is true to the best of my knowledge.)