The B 104 form serves as an essential document for capturing a comprehensive set of information regarding the father on birth records. This two-page document is meticulously structured to include a wide variety of details such as the father's current legal name, mailing address, date of birth, place of birth, and social security number. It goes further to inquire about his highest level of education and his ethnic background, offering multiple choices to accurately represent his identity, including options for Spanish/Hispanic/Latino identification and a detailed section for racial identification. The form allows for the father's information to be recorded in cases of both live births and fetal deaths, emphasizing its role in ensuring the father's details are accurately captured in vital records. With spaces dedicated to filling in the mother's name, date of birth, and medical record number, the form ensures that the information is linked correctly to the child's record. Additionally, it asks for specific identifiers for those who identify as American Indian or Alaska Native, as well as those from Pacific Islander backgrounds, allowing for a more complete understanding of the child's heritage. By providing detailed options for education level, from no formal education to doctorate degrees, the form aims to gather comprehensive data that can be utilized for various statistical and personal purposes.
| Question | Answer |
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| Form Name | Form B 104 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | FD, DVM, Ghanian, washington state birth certificate form |
BIRTH RECORD
FATHER’S INFORMATION |
Page 1 of 2 |
Mother’s Name:
Mother’s Date of Birth:
Medical Record Number:
Father’s Information: Please Print Clearly
What is your current legal name?
First Name |
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Middle Name |
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Last Name |
Suffix |
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What is your mailing address (if different from the mother)? |
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Same as the mother's address |
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Number and Street address, P.O. Box or Rural Route numbers |
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Apartment Number |
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City or Town |
State |
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Zip Code |
If not United States, please enter country. |
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What is your date of birth?
MMDD YYYY
Where were you born?
City or Town |
State or Foreign Country |
What is your social security number?
I don’t have a Social Security number.
Form # B 104 |
01/01/2010 |
BIRTH RECORD
FATHER’S INFORMATION |
Page 2 of 2 |
What is your highest level of education?
Mother’s Name:
Mother’s Date of Birth:
Medical Record Number:
Check the box that best describes your highest level of school completed at the time of your child’s birth.
8th grade or less
9th – 12th grade, no diploma
High school graduate or GED completed Some college credit but no degree Associate degree (AA, AS)
Bachelor’s degree (BA, AB, BS)
Master’s degree (MA, MS, MEng, Med, MSW, MBA)
Doctorate degree ( PhD, EdD, MD, DDS, DVM, LLB, JD)
ARE YOU SPANISH/HISPANIC/LATINO? If you are not Spanish/Hispanic/Latina, check the "NO" box. If you are, check the box that is most appropriate for you.
No, not Spanish/Hispanic/Latino
Yes, Spanish/Hispanic/Latino
Mexican, Mexican American, Chicano
Puerto Rican
Cuban
Other Spanish/Hispanic/Latino PLEASE SPECIFY:
FATHER’S RACE: Check all that apply to indicate what you consider yourself.
Caucasian (white) |
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Asian |
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Black or African American |
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Asian Indian |
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Somali |
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Chinese |
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Ethiopian |
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Filipino |
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Liberian |
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Japanese |
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Ghanian |
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Korean |
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Kenyan |
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Vietnamese |
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Sudanese |
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Hmong |
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Nigerian |
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Cambodian |
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Other African |
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Laotian |
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PLEASE SPECIFY: |
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Other Asian |
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PLEASE SPECIFY: |
American Indian or Alaska Native |
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Other Race |
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Name of Enrolled or Principal Tribe |
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PLEASE SPECIFY: |
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PLEASE SPECIFY: |
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Pacific Islander
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
PLEASE SPECIFY:
Form # B 104 |
01/01/2010 |
FETAL DEATH REPORT
FATHER’S INFORMATION |
Page 1 of 2 |
Father’s Information: Please Print Clearly
What is your current legal name?
Mother’s Name:
Mother’s Date of Birth:
Medical Record Number:
First Name |
Middle Name |
Last Name |
Suffix |
What is your mailing address (if different from the mother)?
Number and Street address, P.O. Box or Rural Route numbers |
Apartment Number |
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City or Town |
State |
Zip Code |
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If not United States, please enter country. |
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What is your date of birth?
MMDD YYYY
Where were you born?
City or Town
What is your social security number?
State or Foreign Country
I don’t have a Social Security number.
Form # FD 104 |
01/01/2010 |
FETAL DEATH REPORT
FATHER’S INFORMATION |
Page 2 of 2 |
What is your highest level of education?
Mother’s Name:
Mother’s Date of Birth:
Medical Record Number:
Check the box that best describes your highest level of school completed at the time of your child’s birth.
8th grade or less
9th – 12th grade, no diploma
High school graduate or GED completed Some college credit but no degree Associate degree (AA, AS)
Bachelor’s degree (BA, AB, BS)
Master’s degree (MA, MS, MEng, Med, MSW, MBA)
Doctorate degree ( PhD, EdD, MD, DDS, DVM, LLB, JD)
ARE YOU SPANISH/HISPANIC/LATINO? If you are not Spanish/Hispanic/Latina, check the "NO" box. If you are, check the box that is most appropriate for you.
No, not Spanish/Hispanic/Latino
Yes, Spanish/Hispanic/Latino
Mexican, Mexican American, Chicano
Puerto Rican
Cuban
Other Spanish/Hispanic/Latino PLEASE SPECIFY:
FATHER’S RACE: Check all that apply to indicate what you consider yourself.
Caucasian (white) |
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Asian |
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Black or African American |
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Asian Indian |
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Somali |
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Chinese |
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Ethiopian |
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Filipino |
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Liberian |
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Japanese |
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Ghanian |
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Korean |
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Kenyan |
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Vietnamese |
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Sudanese |
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Hmong |
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Nigerian |
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Cambodian |
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Other African |
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Laotian |
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PLEASE SPECIFY: |
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Other Asian |
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PLEASE SPECIFY: |
American Indian or Alaska Native |
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Other Race |
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Name of Enrolled or Principal Tribe |
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PLEASE SPECIFY: |
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PLEASE SPECIFY: |
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Pacific Islander
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
PLEASE SPECIFY:
Form # FD 104 |
01/01/2010 |