Arizona Death Registration Worksheet

What Is the Arizona Death Registration Worksheet?

The Arizona Death Registration Worksheet is an essential piece of paperwork that medical professionals, administrators, and funeral directors must use to kickstart the formal death registration process. This form includes several parts that require crucial information about the recently passed individual. They're set up to compile important details like the deceased's personal identification, specifics about their passing such as cause and time, along with information about their parents, spouse, and kids if applicable.

Uses of the Arizona Death Registration Worksheet Form

The primary use of the Arizona Death Registration Worksheet Form is to initiate the process of registering a death in the state of Arizona. After you fill out the form correctly and submit it, it's officially added to the records of the person who has passed away. This is incredibly important for various administrative tasks such as managing the estate of the deceased person, applying for a death certificate, and more. In addition, by offering a thorough explanation of the cause and type of death, it significantly aids medical research and epidemiological studies.

How to Fill Out the Arizona Death Registration Worksheet

To fill out the Arizona Death Registration Worksheet Form on PDFliner, follow these detailed instructions:

1. Start with the decedent's name. Enter the decedent's legal first, middle, last names, and any suffix (e.g., Jr, II) in the respective fields. If the decedent was also known by any other names (AKAs), include those as well.
2. Select the decedent’s sex by choosing 'Female', 'Male', or 'Not Yet Determined' as applicable.
3. Provide the U.S. Social Security Number of the decedent. If none, select 'None'; if unknown, select 'Unknown'.
4. Enter the date of death using the format mm/dd/yyyy.
5. Input the decedent's date of birth using the same date format and specify their age at death in complete years, months, days, hours, and minutes as applicable.
6. Complete the section on the decedent's birthplace by providing the city or town, county, state, and country of birth.
7. Indicate whether the decedent ever served in the U.S. Armed Forces by selecting 'Yes', 'No', or 'Unknown'.
8. For females, if the decedent had a different last name prior to first marriage, provide that name.
9. Input the decedent’s residential address including street, city, county, state, zip code, and country. Also specify whether the residence was within city limits and how long the decedent lived in the state of Arizona.
10. If the decedent resided in an Arizona tribal community, indicate 'Yes' and specify the name of the community.
11. Specify the decedent's marital status by selecting the appropriate status from options such as 'Married', 'Widowed', 'Divorced', etc.
12. Provide the full name (first, middle, last, and suffix) of the surviving spouse and the last name prior to first marriage if applicable.
13. Enter the names of the decedent’s father and mother, including first, middle, last names, and suffixes. For the mother, provide the last name prior to her first marriage.
14. Fill in the informant’s details including their relationship to the decedent, first, middle, and last names, and suffix. Provide the informant’s email address, phone number, and mailing address. The informant must attest to the accuracy of the information with a signature and date.
15. Select the method of disposition such as 'Burial', 'Cremation', 'Donation', etc., and provide the date and places of disposition.
16. For the funeral director’s part, include their name, license number, and the name and address of the funeral home. The funeral director must also sign and date the form to confirm the accuracy of the provided information.
17. Specify the decedent’s occupation, industry, and educational level achieved.
18. Clarify the decedent’s Hispanic origin and race by selecting the appropriate boxes.
19. Provide details of the place of death including the facility name, address, and type of place (e.g., hospital, residence).
20. Complete the certifier’s section by including their type (e.g., Physician, Nurse Practitioner), name, license number, title, address, and other relevant information.

Make sure each entry is accurate and complete, as this form is critical for official records and must be handled with care and precision.