Fillable Printable Application for Certifies Copy of Death Record - Califonia

Application for Certifies Copy of Death Record - Califonia

StateofCalifornia–HealthandHumanServicesAgencyCaliforniaDepartmentofPublicHealth

APPLICATIONFORCERTIFIEDCOPYOFDEATHRECORD

PLEASEREADTHEINSTRUCTIONSONPAGE2BEFORECOMPLETINGTHISAPPLICATION

Aspartofstatewideeffortstopreventidentitytheft,Californialaw(HealthandSafetyCodeSection103526)permitsonlyauthorizedindividualsaslistedonthe

applicationtoreceivecertifiedcopiesofdeathrecords.AllotherswillbeissuedCertifiedInformationalCopiesmarkedwiththelegend,“Informational,NotA

ValidDocumentto

EstablishIdentity.”

Pleaseindicatethetypeofcertifiedcopyyouarerequesting:



IwouldlikeaCertifiedCopy.Thiscopywillestablishtheidentityof

theregistrant.(ToreceiveaCertifiedCopyyouMUSTINDICATE

YOURRELATIONSHIPTOTHEREGISTRANTbyselectingfromthelist

belowANDCOMPLETETHEATTACHEDSWORNSTATEMENT

declaringthatyouareeligibletoreceivetheCertifiedCopy.The

SwornStatementMUSTBENOTARIZEDiftheapplicationis

submittedby

mailunlessyouarealawenforcementorlocalor

stategovernmentalagency.)

 IwouldlikeaCertifiedInformationalCopy.Thisdocumentwillbe

printedwithalegendonthefaceofthedocumentthatstates,

“INFORMATIONAL,NOTAVALIDDOCUMENTTOESTABLISHIDENTITY.”



(ASwornStatementdoesnotneedtobeprovided.)

NOTE:Bothdocumentsarecertifiedcopiesoftheoriginaldocumentonfilewithouroffice.Withtheexceptionofthelegendandredaction

ofsignatures,thedocumentscontainthesameinformation.

Fee:$21percopy(payabletoCDPHVitalRecords).PLEASESUBMITCHECKORMONEYORDER–DONOTSENDCASH

(CDPHcannotbeheldresponsibleforfeespaidincashthatarelost,misdirected,orundelivered).



ToreceiveaCertifiedCopyIam:

Aparentorlegalguardianoftheregistrant(personlistedonthecertificate).(Legalguardianmustprovidedocumentation.)

Apartyentitledtoreceivetherecordasaresultofacourtorder.(Pleaseincludeacopyofthecourtorder.)

Amemberofalawenforcementagencyorarepresentativeofanothergovernmentalagency,asprovidedbylaw,whoisconductingofficialbusiness.

(Companiesrepresentingagovernmentagencymustprovideauthorizationfromthegovernmentagency.)

Achild,grandparent,grandchild,brotherorsister,spouse,ordomesticpartneroftheregistrant.

Anattorneyrepresentingtheregistrantortheregistrant’sestate,oranypersonoragencyempoweredbystatuteorappointedbyacourttoacton

behalfoftheregistrantortheregistrant’sestate.

Anyagentoremployeeofafuneralestablishmentwhoactswithinthecourseandscopeofhisorheremploymentandwhoorderscertifiedcopiesofa

deathcertificateonbehalfofanindividualspecifiedinparagraphs(1)to(5),inclusive,ofsubdivision(a)ofSection7100oftheHealthand

SafetyCode.

Appointedrightsinapowerofattorney,oranexecutoroftheregistrant’sestate.(Pleaseincludeacopyofthepowerofattorney,orsupporting

documentationidentifyingyouasexecutor.)



APPLICANTINFORMATION(PLEASEPRINTORTYPE)Today’sDate:

AgencyName(ifapplicable) AgencyCaseNumber InmateIDNumber

PrintNameofApplicant SignatureofApplicant PurposeofRequest

MailingAddress–Number,Street



AmountEnclosed–DONOTSENDCASH



$_______Check$______MoneyOrder

NumberofCopies



City NameofPersonReceivingCopies,ifDifferentfromApplicant

State/Province ZIPCode

MailingAddressforCopies,ifDifferentfromApplicant

DaytimeTelephone(includeareacode)

()

Country

City State ZIPCode

DEATHRECORDINFORMATION(PLEASEPRINTORTYPE)

Completetheinformationbelowasshownonthedeathrecord,tothebestofyourknowledge.

DECEDENTFIRSTName MIDDLEName LASTName Sex

____Female ____Male

CityofDeath(mustbeinCalifornia)

CountyofDeath DateofBirth–MM/DD/CCYY StateofBirth

DateofDeath–MM/DD/CCYY(OrPeriodofYearstobeSearched) SocialSecurityNumber

Mother/ParentName(First,Middle,Last)



NameofSpouse/DomesticPartnerofDecedent(First,Middle,Last)

DEATH

VS112(01/15) Page1of3

PLEASE ATTACH CHE CK HERE



INFORMATION:



DeathrecordshavebeenmaintainedintheCaliforniaDepartmentofPublicHealthVitalRecordssinceJuly1,1905.



ThenamerequiredonVitalRecords(seeItems1C,6C,7C,9C,and12C)isthenamegivenatbirth,oranamereceivedthrough

adoption,court‐orderednamechange,or

naturalization.AKAs(AlsoKnownAs)andassumednamescannotbeentered

asthelegalnameonthedeathrecord.



INSTRUCTIONS:



1. ONLYindividualswhoareauthorizedbyHealthandSafetyCodeSection103526canobtainaCertifiedCopyofaDeath

Record.(Page1identifiestheindividualswhoare

authorizedtomaketherequest.)AllothersmayreceiveaCertified

InformationalCopywhichwillbemarked,“Informational,NotaValidDocumenttoEstablishIdentity.”



2. Completeaseparateapplicationforeachdeathrecordrequested.



3.CompletetheApplicantInformationsectiononPage1andprovideyoursignaturewhere

indicated.IntheDecedent

Informationsection,providealltheinformationyouhaveavailabletoidentifythedeathrecord.Iftheinformationyou

furnishisincompleteorinaccurate,wemaynotbeabletolocatetherecord.



4. SWORNSTATEMENT:

 Theauthorizedindividualrequestingthecertifiedcopymustsignthe

attachedSwornStatement,declaringunder

penaltyofperjurythattheyareeligibletoreceivethecertifiedcopyofthedeathrecord,andidentifytheir

relationshiptotheregistrant(personlistedonthecertificate)–therelationshipmustbeoneofthoseidentified

onPage1.

 Iftheapplicationis

beingsubmittedbymail,theSwornStatementmustbenotarizedbyaNotaryPublic.

(TofindaNotaryPublic,seeyourlocalyellowpagesorcallyourbankinginstitution.)Lawenforcementandlocal

andstategovernmentalagenciesareexemptfromthenotaryrequirement.

 Youdonothavetoprovidea

SwornStatementifyouarerequestingaCertifiedInformationalCopyofthedeath

record.



5. Submit$21foreachcopyrequested.Ifnodeathrecordisfound,thefeewillberetainedforsearchingfortherecord(as

requiredbylaw)anda“CertificateofNoPublicRecord”willbeissuedtotheapplicant.Indicatethenumberofcopies

youwantandincludethecorrect

fee(s)intheformofapersonalcheckorpostalorbankmoneyorder(International

MoneyOrderforout‐of‐countryrequests)madepayabletoCDPHVitalRecords.PLEASESUBMITCHECKORMONEY

ORDER̶DONOTSENDCASH(CDPHcannotbeheldresponsibleforfeespaidincashthat

arelost,misdirected,or

undelivered).



6. Mailcompletedapplicationswiththefee(s)to:



CaliforniaDepartmentofPublicHealth

VitalRecords–MS5103

P.O.Box997410

Sacramento,CA95899‐7410

(916)445‐2684



DEATH

Page2of3

VS112(01/15)



StateofCalifornia–HealthandHumanServicesAgencyCaliforniaDepartmentofPublicHealth



SWORNSTATEMENT



 I,___________________________________,declareunderpenaltyofperjuryunderthelawsoftheStateofCalifornia,

    (Applicant’sPrintedName)



 thatIamanauthorizedperson,asdefinedinCaliforniaHealthan d Safety CodeSection103526(c),andameligibletoreceivea



 certifiedcopyofthebirth,death,ormarriagecertificateofthefollowingindividual(s):



NameofPersonListedonCertificate

Applicant’sRelationshiptoPersonListedonCertificate

(MustBeaRelationshipListedonPage1ofApplication)













(TheremaininginformationmustbecompletedinthepresenceofaNotaryPublicorCDPHVitalRecordsstaff.)



 Subscribedtothis______dayof______________,20___,at________________________________,_____________.

    (Day) (Month)   (City)(State)



______________________________________________________

(Applicant’sSignature)



Note:Ifsubmittingyourorderbymail,youmusthaveyourSwornStatementnotarizedusingtheCertificateofAcknowledgment

below.TheCertificateofAcknowledgmentmustbecompletedbyaNotaryPublic.(Lawenforcementandlocalandstate

governmentalagenciesareexemptfromthenotaryrequirement.)

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

     

CERTIFICATEOFACKNOWLEDGMENT

Anotarypublicorotherofficercompletingthiscertificateverifiesonlythe

identityoftheindividualwhosignedthedocumenttowhichthiscertificateis

attached,andnotthetruthfulness,accuracy,orvalidityofthatdocument.



 Stateof_______________________)

    

 Countyof______________________)



On____________beforeme,_________________________________,personallyappeared_______________________________________,

(insertnameandtitleoftheofficer)

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whoprovedtomeonthebasisofsatisfactoryevidencetobetheperson(s)whosename(s)is/aresubscribedtothewithininstrumentand



acknowledgedtomethathe/she/they

executedthesameinhis/her/theirauthorizedcapacity(ies),andthatbyhis/her/theirsignature(s)on



theinstrumenttheperson(s),ortheentityuponbehalfofwhichtheperson(s)acted,executedtheinstrument.IcertifyunderPENALTYOF



PERJURYunderthelawsoftheStateofCaliforniathattheforegoingparagraphistrue

andcorrect



WITNESSmyhandandofficialseal.

(SEAL)

 

 _________________________________________________________



SIGNATUREOFNOTARYPUBLIC

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