Death Certificate Application Form

Information of the decedent

Complete the following information regarding the details of the deceased person on record.

Decedent's State of Death *

California
Arkansas
Alabama
Alaska
Arizona
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

Decedent's State of Birth (Optional)

Decedent's City/Town of Death *

Decedent's County of Death, if known/applicable (Optional)

Decedent's Date of Death

Month of Death *

Day of Death *

Year of Death *

Decedent's Date of Birth

Month of Birth (Optional)

Day of Birth (Optional)

Year of Birth (Optional)

Decedent's Social Security number if known (Optional)

Decedent's personal information

Please enter the Full name of the person on record at time of death as shown on the Death Certificate.

First Name *

Middle Name (Optional)

Last Name *

Full Name of Decedent's Mother / Parent

First name *

Middle name (Optional)

Last name *

Full Name of Decedent’s Surviving Spouse or Domestic Partner as Recorded on Death Record

First name (Optional)

Middle name (Optional)

Last name (Optional)

Applicant information

Contact information

Please enter your full name as shown on your ID and your contact information.

First Name *

Middle Name (Optional)

Last name *

Phone number *

Delivery information

Please enter the physical address where you want the certificate to be delivered.

City *

State *

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York State
New York City
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

Zip code *

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