Fillable Form Hc1238gc - Death Certificate Application printable pdf download

COUNTY OF HENNEPIN

$0.00

DCN/Cert. # ________________

# of Copies: _____ Amount: _______

ID Type

STATE OF MINNESOTA

Initials & Emp #___________________

ID #

Issue Date: _______________________

DEATH CERTIFICATE APPLICATION

NAME OF DECEASED:

First

Middle

Last

DATE OF DEATH:

PLACE OF DEATH:

MM/DD/YYYY

County

Is this copy desired for VA Benefits?

Yes

(If yes, furnish Claim Form.)

Quantity and cost – Make checks payable to: HENNEPIN COUNTY TREASURER

$13 first certified record without cause of death - only for records 1997 to present (tangible interest required).

$13 first certified record with cause of death (tangible interest required).

$6 each additional copy of the same record issued at the same time as the first copy.

$13 uncertified record (tangible interest and notarization of applicant’s signature NOT required).

Select only one:

I am the child of subject

I am the spouse of subject

I am the parent listed on the record

I am the grandparent of the subject

I am the grandchild of subject

I am the sibling of the subject

I am the party responsible for filing the death record.

I am the personal representative and the certified copy is required for the administration of the estate.

524.1-201, and the certified copy is required for the

I am a successor of the subject, as defined in

MN Statutes section

administration of the estate.

I am a trustee of a trust and the certified copy is for the proper administration of the trust.

I have documentation that the record is necessary for the determination or protection of personal or property rights pursuant to

rules adopted by the commissioner of health. (Requests must be referred to the State Registrar)

I represent an adoption agency and the record is needed to complete a confidential post-adoption search.

I represent a local, state or federal government agency and it is necessary to secure a certified copy for authorized agency duties.

(Submit a copy of your employee ID)

I am an attorney and I have attached proof of my licensure.

I am presenting your office with a court order issued by a court of competent jurisdiction. (Must be a certified copy)

I am a representative authorized by a person listed above. (Must have a notarized statement from a person listed above)

PENALTIES: Any person who willfully and knowingly makes false application for a death certificate is guilty of a misdemeanor or gross

misdemeanor.

(MN Statutes section 144.227, subdivision

THE FOLLOWING INFORMATION IS ABOUT THE PERSON COMPLETING THIS APPLICATION

YOUR NAME:

DATE OF BIRTH:

MM/DD/YYYY

ADDRESS:

City

State

Zip

The information requested on this application is required by MN Statutes,

Section 144.225, Subdivision 7

and

MN Rules, Part 4601.2600

. I certify

that the information provided on this application is accurate and complete to the best of my knowledge.

Print Form

Clear Form

SIGNATURE:

DATE:

PHONE:

SUBMIT REQUESTS BY MAIL OR FAX TO:

Signature must be notarized (except for uncertified)

if applying by mail or fax

VITAL RECORDS

Hennepin County Government Center

Subscribed and sworn before me this

__ d

__ ay of_______, 20___

300 South 6th St, Suite A025

Minneapolis MN 55487-0026

____________________________________________________

Fax # 612-348-2010

Notary

My Commission expires:

(seal)

HC1238GC (06/14)

Form Hc1238gc - Death Certificate Application

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