Vital Records Death Application Form
Download a blank fillable Vital Records Death Application Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Vital Records Death Application Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Vital Records Death Application
A photocopy of a current government, school or employer photo identification of the
applicant must be submitted with all requests.
Applications without proper identification will be returned unprocessed.
Name of applicant:_____________________________________________________________ Day phone number:______________________
Address: _____________________________________________________________________________________________________________
City:______________________________________________ State:_______________________________ Zip code:_______________________
Email address: ________________________________________________________________________________________________________
Note: Mail from Vital Records will not be forwarded by the USPS.
Address certificate to be mailed to if different than applicant’s address:
Name: _______________________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________________
City: ___________________________________________________________ State: _________________________ Zip code: ______________
Your relationship to person named on the certificate. (Check one - will be used to determine entitlement)
____ Family member (specify) ____________________________________________________________________________________________
____ Legal Guardian
____ Legal representative (for whom?)______________________________________________________________
____Other (specify)_____________________________________________________________________________________________________
For what purpose are you requesting this certificate? _______________________________________________________________________
By signing this application, I understand that making a false application for a vital record is a felony under state law.
Signature of applicant: __________________________________________________________________________________________________
INFORMATION FOR DEATH CERTIFICATE BEING REQUESTED:
Name of deceased: _____________________________________________________________________________________________________
First
Middle
Last
Suffix
Date of death: _____________________ Sex:_______ Age at death:_______ City/County of death:__________________________________
FEES
SEARCH FEE: A $12 "search fee" is required by SC Law Section 44-63-110. The $12 search fee is non-refundable. The required search fee in-
cludes one (1) certification, if record is located. Additional copies purchased at the same time are $3 each. Acceptable methods of payment for mail
requests are a money order or cashier’s check made payable to SC DHEC. Onsite customer service also accepts credit and debit cards and cash.
Specify type of certification: o Death Long
o Death Short
o Death Statement
Required Search Fee (Non-refundable, Includes one copy if found)…………………………..........................................….....…….. $12.00 $12.00
Each additional copy of type specified above………………………………......................………..…….______________________x $ 3.00 ______
Number of additional copies
Total fees submitted:_________
Send completed application to: SC DHEC – Vital Records, 2600 Bull Street, Columbia, SC 29201
Along with completed application, be sure to include payment and photocopy of proper identification.
OFFICE USE ONLY
SFN:
DCN:
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
DHEC 2594 (09/2015)
See back for Instructions and Information
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business