Form Acr 406 - Application For Certified Copy Or Search Of A Death Record - 2014
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1
2RIVERSIDE COUNTY
ASSESSOR-COUNTY CLERK-RECORDER
APPLICATION FOR CERTIFIED COPY OR SEARCH OF A DEATH RECORD
PLEASE REVIEW THE INSTRUCTIONS ON THE BACK BEFORE COMPLETING
DEATH RECORD or CERTIFICATE OF NO RECORD INFORMATION
FEE $21.00
1
Name of Deceased_____________________________________________________________________________________
First
Middle
Last
Date of Death _______________________________
Date of Birth ___________________________________
City of Death ________________________________
Number of Copies ___________________________
I am requesting an AUTHORIZED copy
I am requesting an INFORMATIONAL copy
2
If you are requesting an Informational copy, please skip to section
4.
To obtain an Authorized Certified Copy you must check the appropriate box below: I am:
3
The parent or legal guardian of the person listed on the death record.
A child, grandparent, grandchild, sibling, spouse or domestic partner of the person listed on the death record.
A member or representative of a government agency, as provided by law, who is conducting official business. (Companies
representing a government agency must provide authorization from the government agency.)
A person who has a court order to obtain the record.
An attorney representing the person or the person’s estate whose name is listed on the death record or any person or agency
appointed by court to act on behalf of the person or the person’s estate whose name is listed on the death record. (If you are
requesting a Certified Copy under a power of attorney, please include a copy of the power of attorney with this application form.)
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 any individual specified in paragraphs (1) to (5), inclusive, of subdivision (a) of
Section 7100.
Requested by:
Mail/Issue To:
4
________________________________________
________________________________________
Name
Name of Person Receiving Copies, If Different from Applicant
________________________________________
________________________________________
Street Address
Mailing Address for Copies, if Different from Applicant
________________________________________
________________________________________
City
State
Zip
City
State
Zip
(________)_________________________
_____________________________________
Phone #
I.D. #
5
I, _________________________________ swear or affirm under penalty of perjury that I am an authorized person,
(Print Full Name)
as defined in California Health and Safety Code Section 103526 (c), eligible to receive a certified copy of the death
record identified on this application form.
____________________________________ at ____________________________ _______
Sworn:
Date (mm/dd/ccyy)
City
State
_____________________________________________________________________
Signature:
(Applicant Signature)
(If ordering in person you must sign in front of the Clerk)
BELOW SECTION FOR OFFICE USE ONLY
Receipt #
Check #
Total $ Due
Amount Paid
Year / Certificate #
Cash
Check Debit / Credit
Long Amount
Refund Amount
Counter
Mail
Gov’t Agency
Govt. Stamped
Credit Card # / Exp. Date
Type of I.D., Identifying Numbers and Exp. Date
Clerks Initials
Do Not Charge Fee, Contact State
Charge Search Fee, Contact
State or ________________ Searched years from ___________ to ____________ by: ____________
ACR 406 (Rev. 11/2014)
Available in Alternate Formats
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