- Birth: Facility Affidavit for Correction Application
- Death: Facility Affidavit for Death Correction Application
- Marriage or Divorce: Facility Affidavit for Correction
- Cause of Death Worksheet for Report of Death (PDF)
- Demographics Worksheet for Report of Death (PDF)
Complete Facility Affidavit for Correction form
- Information to identify the record
- First, middle, last name listed on the record
- Date of event
- Place of event
- Parent(s) first, middle, last name listed on the record
- Name
- Title
- Mailing address
- Telephone number
All requested corrections or changes to the record must be identified on the Facility Affidavit for Correction form and listed on separate lines.
A Facility Affidavit for Correction form may not be used for first, middle, or last names that have already been changed due to court order from adoption, parentage, or legal name change.
What can be amended on a birth record
The facility or health care provider responsible for submitting a report of live birth to the Department may request an amendment only within one year of the date of the event. A facility or health care provider may request an amendment for a birth record they submitted to correct:
- A typographic or administrative error made during the registration process. A supporting document with the correct information, such as a birth filing form completed by the family, must accompany the request.
- T he date and time of birth. The facility or health care provider must submit the facility or health care provider’s records that reflect the correct date and time of birth as supporting documentation along with the request.
Acceptable Proof Documentation
- Birth Filing Form
- Hospital Intake Form [for Mother/Birth Parent’s Information]
Only a certifier can request to amend the cause of death and injury sections of a death or fetal death record. A certifier is any of the following licensed practitioners who signed the death certificate:
- Physician
- Osteopath
- Physician’s Assistant (PAC)
- Advanced Registered Nurse Practitioner (ARNP)
- Midwife
- Local Health Officer
- Medical Examiner
- Coroner
Once the record is filed with the state or local registrar, date of death, and time of death can only be changed by the medical certifier, medical examiner, coroner, or local health officer who has jurisdiction.
Only the entities listed bel ow can request an amendment to the cause of death section of a death or fetal death record:
Eligible Entity
Requirements
The original certifier* who signed or electronically approved the cause of death section
*Certifier includes medical certifier, medical examiner, coroner, or local health officer
• Facility Affidavit for Correction form.
• No proof documentation is required.
Another medical examiner or coroner within the same office as the original listed on the record
• Facility Affidavit for Correction form.
• No proof documentation is required.
Another certifier* when the original certifier is no longer available or not available for a month or more
*Certifier includes medical certifier, medical examiner, coroner, or local health officer
• The administrator of the location or facility indicates on the Facility Affidavit for Correction form that the original certifier is not available (ex. death or retirement) and that another certifier will be submitting the Facility Affidavit for Correction form.
• No proof documentation is required.
• This will not change the original certifier name listed on the record unless such a change is specified on the Facility Affidavit for Correction form by the new certifier.
A medical certifier, coroner, medical examiner, or local health officer must submit a Facility Affidavit for Correction form within five calendar days of receipt of an autopsy result or other information that completes or amends the cause of death from that originally filed with the department. RCW 70.58A.200(12) .
If you are not completing the cause of death and injury information amendment online, then you must complete a Facility Affidavit for Death Correction form. The affidavit must include:
- Information to identify the record
- First, middle, last name listed on the record
- Date of event
- Place of event
- Parent(s) first, middle, last name listed on the record
- Name
- Title
- Mailing address
- Telephone number
All requested corrections or changes to the record must be identified on the Facility Affidavit for Death Correction form and listed on separate lines.
Facility Correction for a Death Certificate
- Information to identify the record
- First, middle, last name listed on the record
- Date of event
- Place of event
- Parent(s) first, middle, last name listed on the record
- Name
- Title
- Mailing address
- Telephone number
All requested corrections or changes to the record must be identified on the Facility Affidavit for Death Correction form and listed on separate lines.
Any signature on a death or fetal death record will not be amended.
Death or fetal death records registered through a court order can only be amended or corrected with a court order. A Facility Affidavit for Correction form cannot be used.
Acceptable Proof Documents:
- Funeral Home Intake Sheet
- Hospital/medical record
- Full Numident Report (Social Security)
- Social Security Abstract
- Copy of passport or enhanced identity document
- Certificate of Naturalization
- Permanent resident card (I-551)
- Health or life insurance policy
- Military record (DD-214)
- Official school transcripts
- Government agency records for establishment of benefits (such as social services or Medicaid)
Only documents listed below are exempt from the five-year rule and will be accepted from any period of time:
- Passport
- Permanent resident card (I-551)
Who can Request an Amendment
- For marriages, the Officiant named on the record may change only the date and place of marriage. The officiant must use the Facility Affidavit for Correction form to make this change. No proof documentation is required.
- For divorces, the County Clerk named on the record may change only the date of divorce. The County Clerk must use the Facility Affidavit for Correction form to make this change. No proof documentation is required.
Complete Affidavit for Correction form
- The record type to be amended
- Information to identify the record
- First, middle, last name listed on the record
- Date of event
- Place of event
- Spouse A first, middle, last name
- Spouse B first, middle, last name
- Name
- Relationship to subject of the record
- Mailing address
- Telephone number or email address
All requested corrections or changes to the record must be identified on the Facility Affidavit for Correction form and listed on separate lines.
Submitting the Facility Affidavit for Correction Application
You can submit your completed application to the Department of Health by mail or fax or electronic submission.
1) By Mail
Center for Health Statistics
Attn: Amendments
P.O. Box 47814
Olympia, WA 98504-78142) By Fax or electronic submission
Call (360) 236-4300 to coordinate with the Amendment Services Team.
