Form Sfn 58647 - Funeral Directors Worksheet For Completing A Facts Of Death Record

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NORTH DAKOTA FUNERAL DIRECTOR'S WORKSHEET FOR COMPLETING A FACTS OF

DEATH RECORD

NORTH DAKOTA DEPARTMENT OF HEALTH

DIVISION OF VITAL RECORDS

SFN 58647 (10-2013)

1. Decedent's Legal Name (First, Middle, Last, Suffix)

Also Known As (AKA) (1)

Also Known As (AKA) (2)

2. Gender

Unknown

Male

Female

3. If Female, Maiden Name (last name prior to marriage)

4. Social Security Number *

5. Date of Death

6. Time of Death (military)

7. Date of Birth

8. Age (in years) at Last Birthday

If under 1

If under 1 day

Months

Days

Hours

Minutes

9. Place of Birth - State or Foreign Country. If Canada, please also list province.

10. Address Where Decedent Usually Lived

Apartment Number

Inside City Limits

Yes

City

County

State

ZIP Code

11. Decedent in United States Armed Forces

12. Marital Status of Deceased

Married

Widowed

Never Married

Yes

Unknown

Married, but separated

Divorced

Unknown

13. Surviving Spouse's Name (First, Middle, Last) If wife, give last name prior to first marriage.

14. Decedent's Father's Name (First, Middle, Last, Suffix)

15. Decedent's Mother's Name Prior to First Marriage (First, Middle, Last, Suffix)

16. Informant's Name (First, Middle, Last, Suffix)

17. Informant's Relationship to Decedent

18. Informant's Mailing Address

City

State

ZIP Code

19. Death Occur in a Hospital (If YES, complete facility information)

Yes

- Complete facility information

Inpatient

Emergency Room/Outpatient

Dead on Arrival

Facility Name

City

County

State

ZIP Code

20. Death Occurred Somewhere Other Than a Hospital

Hospice Facility

Nursing Home/Long-Term Care Facility

Decedent's Home

Other. Specify:

Facility Name (if not in an institution, give street and number)

City

County

State

ZIP Code

21. Method of Disposition

Burial

Other. Specify:

Cremation

Entombment

Donation

Removal from state

22. Place of Disposition

Name of Cemetery, Crematory, or Other

City

County

State

23. Decedent's Level of Education

High school graduate or GED completed

Bachelor's Degree (BA, BS)

Unknown

8th grade or less

Some College credit but no degree

Master's Degree (MA, MS)

9th - 12th grade, no diploma

Associate Degree (AA, AS)

Doctorate Degree (PHD, MD)

* Based on federal law (42 U.S.C. §§ 652(a)(7) and 666(a)(5)(C)(iv)), the social security number has been determined to be a mandatory data element for

this form and will be used for identification purposes. Failure to disclose this information will not affect the validity of this form.