Form Vs-39d - Request For Copy Of Death Certificate
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1REQUEST FOR COPY OF DEATH CERTIFICATE
VS-39D
Revised: 8/17/00
PLEASE PRINT
DO NOT MAIL CASH
FULL NAME
SEX
DATE OF DEATH
FIRST
MIDDLE
LAST
(OR LAST KNOWN TO BE ALIVE)
DEATH
M
F
CERTIFICATE
OF:
PLACE OF DEATH
DATE OF BIRTH
PLACE OF BIRTH
(TOWN)
(MONTH/DAY/YEAR)
(TOWN, STATE OR FOREIGN
COUNTRY)
FATHER’S NAME
MOTHER’S NAME
IF MARRIED, SPOUSE’S NAME
PLEASE NOTE: THE SOCIAL SECURITY NUMBER OF THE DECEDENT IS CONFIDENTIAL IN ACCORDANCE WITH PA 97-7. AS
SUCH, ONLY SPECIFIC INDIVIDUALS, APPROVED BY THE DEPARTMENT OF PUBLIC HEALTH, WILL BE ISSUED CERTIFIED
COPIES OF DEATH CERTIFICATES INCLUDING THE SOCIAL SECURITY NUMBER OF THE DECEDENT.
ALL OTHER CERTIFIED COPIES WILL MASK THE SOCIAL SECURITY NUMBER OF THE DECEDENT TO COMPLY WITH THE
PROVISIONS OF PA 97-7.
PERSON MAKING THIS REQUEST:
NAME: ______________________________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
ADDRESS: ___________________________________________________________________________________________________________
NUMBER
STREET
TOWN/CITY: _____________________________________
STATE: ________________ZIP CODE: _____________________
X
_____________________________________________________________________________________________
SIGNATURE:
THE LEGAL FEE IS $5.00 PER COPY.
NUMBER OF COPIES WANTED:
_________________
AMOUNT ATTACHED:
$_________________________
FEE: $5.00 PER COPY MONEY ORDER MADE PAYABLE TO THE TOWN/CITY OF DEATH
MAIL THIS REQUEST WITH PAYMENT TO THE TOWN CLERK AT THE TOWN/CITY OF DEATH
FOR TOWN CLERK ADDRESSES PLEASE SEE ALPHABETICAL LISTING BY TOWN
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Parent category: Legal