Death Certificate Application

State of Death

Information of Person of Record

Decedent Full Name

Decedent First Name

Decedent Middle Name

Decedent Last Name

Decedent Maiden Name

Decedent Last Name at Birth (If Changed)

Decedent Suffix

If name was changed since birth, indicate new name:

Last Known Address

Race

Sex

Male Female

Occupation

Date of Birth

Place of Birth

State of Birth

Social Security Number

Person of Record's Family

Parents Names

Mother/Parent A Full Name

Mother/Parent A Full Maiden Name

Mother/Parent A First Name

Mother/Parent A Middle Name

Mother/Parent A Maiden/Last Name

Mother/Parent A Maiden Name

Mother/Parent A Last Name

Mother/Parent A Suffix

Mother/Parent A Birthplace

Father/Parent B Full Name

Father/Parent B First Name

Father/Parent B Middle Name

Father/Parent B Maiden/Last Name

Father/Parent B Maiden Name

Father/Parent B Last Name

Father/Parent B Suffix

Father/Parent B Birthplace

Martial Status at Death

Spouse/Domestic Partner Full Name

Spouse/Domestic Partner First Name

Spouse/Domestic Partner Middle Name

Spouse/Domestic Partner Last Name

Spouse/Domestic Partner Suffix

Spouse/Domestic Partner Maiden Name

Spouse/Domestic Partner's Home Address

Details of Death

If deceased was an infant, was it stillborn?

Yes No

Event Type

Death Fetal Death Stillbirth

Event Type

Death Fetal Death

Did the stillbirth event occur after 20 weeks or less gestation?

Yes No

Date of Death

Age at Death

Hospital of Death

Street Address or Hospital of Death

Location of Death

Attending Physician First Name

Attending Physician Middle Name

Attending Physician Last Name

City of Death

County of Death

Place of Death (City and/or County)

Place of Death

Borough of Death

Island of Death

Funeral Director Name

Name of Funeral Home

Funeral Home Address

Funeral Home City

Funeral Home County

Funeral Home State

Funeral Home Telephone Number

City/County where buried

Name of Attending Certifier

Attending Certifier Address

Customer Info

Applicant Name

First Name

Middle Name

Last Name

Suffix

Phone Area Code

Phone Number

Phone Number (First 3 Digits)

Phone Number (Last 4 Digits)

Work Phone Number

Email address

Email Address (First Part)

Email Address Domain Name

Email Address Domain Name Extension

Your Birthdate

Physical Residence Street Address

Physical Residence City

Physical Residence State

Physical Residence ZIP code

Type of Current Valid Photo ID

Photo ID Number

State of Issuance

Expiration Date

Relation to person of record

Relation to person on record

Relation to person of record

I am applying for the death record of

Relation to person of record

I am applying for the death record of

Relation to person of record

Relation to Person on Record

Relation to person on record

Family, specify

Other Relative

Who are you the authorized representative for?

Specify your personal/property interest

Address where you would like the Death Certificate to be delivered

Street

Apt, Suite, Floor, Etc.

City

State

Zip Code

City, State ZIP

Delivery Preference

Mailing Address

By checking this box, I agree to submit the information provided to this website, and I authorize Vital Records Online to use my information to fill all necessary documents in order to prepare my application materials. I understand that VitalRecordsOnline.com is a private document preparation service and that I am hiring them to prepare my birth certificate application materials. I understand there is a service fee charged by VitalRecordsOnline.com and I will pay the health department required fee directly by check or money order. I understand I may have to provide additional documents or notarized documents to the health department in order to prove my identity. I understand that I may receive newsletters from Vital Records Online. By submitting the form above, I agree to these terms and the terms of this website.

State of Death

Information of Person of Record

Person of Record's Family

Details of Death

Customer Info

Certificate Request

Address where you would like the Death Certificate to be delivered

FAQs

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State of Death

Information of Person of Record

Person of Record's Family

Details of Death

Customer Info

Certificate Request

Address where you would like the Death Certificate to be delivered

FAQs