Fillable Death Certificate Application Form - Oklahoma

Death Certificate Application

Division of Vital Records

Phone:

1000 NE 10

Street

PO Box 53551

Walk-in Hours:

(405) 271-4040

Oklahoma City, OK 73117

Oklahoma City, OK 73152

Mon-Fri 8:30-4:00

Requirements:

Section 1 must be completed in full.

Section 2 is optional but may provide additional information to locate the record

Enclose a copy of a current legal photo ID (See back for list of acceptable IDs)

Enclose appropriate fees

Person applying to receive a death certificate must sign below and meet eligibility requirements (SEE BACK)

If submitting by mail, enclose a self-addressed stamped envelope

Section 1: REQUIRED INFORMATION: Complete in full



Check box if death was stillbirth or fetal death

Full Name of Deceased: _____________________

________________________

______________________________________

First

Middle

Last

Date of Death: _____ / ______ / _____

Place of Death _____________________________________________, OKLAHOMA

Month

Day

Year

City and/or County

Applicant Information:

Name ___________________________________________

Daytime Telephone Number: (______) _______ - __________

Mailing Address ____________________________________________Apt _______

City, State and Zip ______________________________________

E-mail Address_______________________________________________________________  No email

Relationship to the Decedent:  Family: specific ___________________  Legal Rep of the Estate

 Funeral Director  Court Order  Other ______________

 Estate Settlement  Genealogy

 Other, specify: ___________________________________

Purpose for which the death certificate is needed:

By signing below, I declare that all information provided on this application is true and correct.

Signature: ______________________________________________________________

Date Signed: _____________________________

(Application will not be processed without the signature of the requestor and established eligibility)

Section 2: OPTIONAL INFORMATION: May assist us in locating the record

___________________________

Social Security Number: _____-_____-_____

Gender:

Spouse Name:

Female

Male

_________________________________________________________________________

Funeral Home Name and Address:

Date of Birth: _____ / ______ / _____

Place of Birth: _______________________________________, ___________________

Month

Day

Year

City and/or County

State

Father’s Name and Birthplace: _____________________________________________________________________________________

Mother’s Name and Birthplace: _____________________________________________________________________________________

Fees

A fee is to be paid for a search of the files or records, even when no copy is available. Search fees are non-transferable and non-refundable.

_______ Number of certified copies requested ($15 per copy which includes a search fee)

_______ Amendment Fee ($35 Required to amend non-medical certification items. Includes 1 certified copy.)

_______ Total Amount enclosed

Make checks payable to OSDH. Do not send cash by mail.

FEES: A record search is $15 and includes the issuance of one certified copy if the record is found; additional copies are $15 each. If no record is found; the

fee will not be refunded. The fee to amend a record is $35 ($20 processing fee + $15 for one certified copy). Should you receive a request for more information,

please respond promptly as all fees and files will expire one year after the date paid.

OFFICE USE ONLY

Mail

Front Desk

Reviewed by: ____________________ Date: ______ / _____ / ______

Clerk: ______________ Date: ________ / _______ / ________

Fees Enclosed: $_________________ Fees Due: $ _______________

Fees Paid: $ _______________

Check

Cash

ID Enclosed: _____________________