INSTRUCTIONS FOR ONLINE USE: You may fill this form out online by clicking on a field below and
using your Tab key to advance to the next field. After entering your information you will need to print the
form, sign and date it, and mail it along with your fee to:
Division of Vital Records, Oklahoma State Department of Health
1000 Northeast 10th Street, Post Office Box 53551
Oklahoma City, Oklahoma 73152-3551
APPLICATION FOR SEARCH AND CERTIFIED COPY OF DEATH CERTIFICATE
Facts Concerning This Death
Full name of deceased ________________________________________________ Race __________________
Date of Death _____________________
Place of death _______________________________, OKLAHOMA
(Mo.)
(Day)
(Year)
(County)
(City)
Check box is death was stillbirth or fetal death
Funeral director in charge______________________________________________________________________
Funeral Home Address ________________________________________________________________________
Purpose for which this copy is needed__________________________________________________________
Signature of person making this application _______________________________
Date ________________
PLEASE PRINT CORRECT MAILING ADDRESS BELOW:
_____________________________________________________
Number of copies
(Name)
wanted @ $10.00 __________
_____________________________________________________
Fee enclosed
$ __________
(Street Address)
ENCLOSE A STAMPED
SELF-ADDRESSED
_____________________________________________________
ENVELOPE WITH THIS
(City)
(State)
(Zip)
APPLICATION