Death Certificate Request

       NON-REFUNDABLE SEARCH FEE
                                                 Proof of identity of applicant:                      STATE PERSONNEL USE ONLY ________
                 Death Certificate               Applicant must provide one of these:
                                                     ❒   Driver’s License
Full Name of Decedent:                                                                                CERT# _______________ # of copies_____
                                                     ❒   Passport
                                                     ❒   Government issued picture I.D.               AMOUNT PAID
Date of Death:                                   OR two of these:
Place of Death:                                      ❒   Utility bills                                CASH ______ CHECK#______ CC_______
Applicant Name:                                      ❒   Bank statements
                                                     ❒   Vehicle registration
                                                                                                      ID Shown:
Applicant Address:                                   ❒   Income tax return
                                                     ❒   Personal Check w/ address
                                                                                                      ID #:
                                                     ❒   A previously issued vital record
                                                     ❒   Letter from government agency requesting
Indicate your Relationship to the person on                                                           Expires:
                                                         record (DHHS, WIC)
requested record below:                              ❒   Department of Corrections I.D. card
              ❒ Spouse                               ❒   Social Security Card                         Notes:
              ❒ Registered Domestic Partner          ❒   DD 214
              ❒ Parent                               ❒   Hospital; birth worksheet
              ❒ Funeral Director                     ❒   License/rental agreement

❒ Informant ❒ Pay stub

❒ W-2

❒ Guardian

❒ Voter Registration card

❒ Descendant

❒ Disability award from SSA

❒ Attorney of person on record

❒ Other _________________

❒ Genealogist ID # ____________ Establishing eligibility to acquire record:

❒ Related applicants must provide proof of By signing below, I swear/affirm that the lineage. information above is true and correct. ❒ Domestic Partners must provide proof of Applicant Signature: registration of domestic partnership

❒ Attorneys must provide a signed, notarized release from family Today’s Date:

❒ Genealogists must provide a state-issued $15 for 1st copy, $6 for each additional copy card NON-REFUNDABLE SEARCH FEE incounterdthform.doc R 12/2013

❒ Do not retain copies of proof provided or note any specific numbers