Death Record Form - Utah Vital Records Page 5
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6Death Record Form
Page 3 of 4
Informant’s Relationship to the Decedent
___________________________________________________________________
Informant’s Mailing Address
__________________________________________________________________________________________ ________________
Address
Apartment #
____________________________ ____________________________ ____________________ ___________________________
State
City
Zip
Country if Outside the US
20. Is Decedent Of Hispanic Origin?
Yes
No
Unknown
(If YES, Check The Box That Best Describes Whether The Decedent Is Spanish/Hispanic/Latino)
Mexican, Mexican American Chicano
Puerto Rican
Cuban
South American
Other Spanish/Hispanic/Latino
(Specify) _________________________
21. Decedent’s Race
(Check One Or More Races To Indicate What The Decedent Considered Him/Herself To Be)
White
Korean
Other Asian
Black or African
Samoan
Specify) _________________________
(
American
Vietnamese
Other Pacific Islander
Chinese
Guamanian Or Chamorro
Specify) _________________________
(
Japanese
American Indian Or Alaska
Other
Native Hawaiian
Native/ Name Of Principal
Specify) _________________________
(
Filipino
Tribe _________________________
Unknown
Asian Indian
22. Decedent’s Level of Education
th
8
Grade or Less
Some College Credit but No Degree
Doctorate (PhD, EdD,
th
th
9
– 12
Grade, Less – No
Associate Degree (AA, AS)
Or Professional Degree)
Diploma
Bachelor’s Degree (BA, AB, BS)
(MD, DDS, DVM, LLB,
High School Graduate or
Master’s Degree (MA, MS, ME)
JD)
GED Completed
None
Unknown
Death and Dispositioner Information:
23. Decedents Time of Death
24-Hour Clock
_______: _______
24. Date Deceased Last Attended by Physician or Agent
______________________________ ______, ____________
Month
Day
Year
Place of Death:
25. Did Death Occur in a Hospital
Inpatient z
Emergency Room/Outpatient z
Dead on Arrival
Facility Name ________________________________________________________________________________________________
26. Did the Death Occur Somewhere other than a Hospital
Nursing Home/ Assisted Living
Decedent’s Home
Other (Specify)_______________________
Facility Name ________________________________________________________________________________________________
(If Outside a Facility, Give Street Address of Location)
_____________________________________________________________________________________________________________
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