Form Dh 727 - Application For Florida Death Or Fetal Death Record

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State of Florida

Department of Health - Vital Statistics

APPLICATION FOR FLORIDA DEATH OR FETAL DEATH RECORD

Read the FRONT AND BACK OF this application: Anyone may apply for a death certification. When cause of death information is also requested and the death occurred

less than 50 years ago, a copy of valid photo ID must accompany this application AND the applicant OR person being represented must be an eligible person as outlined

in statute (see Eligibility on the reverse of this form). Relationship to the decedent must be entered in the space provided at the bottom of this form when requesting cause

of death. Acceptable forms of valid ID are: driver's license, state identification card, passport, and/or military ID card. When requesting a death certification without cause

of death OR if the death occurred over 50 years prior to the request, photo identification is not required. If a funeral home or an attorney, see additional information under

Eligibility on reverse side of this form to ensure proper completion of this application.

SECTION A - INFORMATION ON TYPE OF RECORD AND DECEDENT PLEASE CHECK APPROPRIATE BOX:

DEATH

FETAL DEATH

FIRST

MIDDLE

LAST

SUFFIX

NAME OF DECEDENT

IF MARRIED AND APPLICABLE, PRIOR SURNAME (If known)

ALIAS NAME(IF APPLICABLE)

MONTH

DAY

YEAR (4-DIGIT)

STATE FILE NUMBER (If known)

SEX

DATE OF DEATH

Below indicate the range of years to be searched

PLACE OF DEATH CITY OR TOWN

PLACE OF DEATH COUNTY

ADDITIONAL YEARS

(If not known, enter Unknown )

TO BE SEARCHED

(Required only when exact year is not known)

FIRST

MIDDLE

LAST

SUFFIX

NAME OF SURVIVING SPOUSE AS

RECORDED ON DEATH RECORD

(if applicable and if known)

SOCIAL SECURITY NUMBER (If known)

FUNERAL HOME NAME(If known)

SECTION B – FEES & PAYMENT: A RECORD SEARCH REQUIRES ADVANCE PAYMENT OF A NON-REFUNDABLE SEARCH FEE OF $5.00

CERTIFICATION - Fee of $5.00 entitles applicant to ONE certification. Check appropriate box:

$5.00

Without Cause of Death

With Cause of Death (See Eligibility on the reverse side of this form)

Additional Computer Certifications WITHOUT Cause of Death:

$4.00 for each subsequent certification

$4.00

Additional Computer Certifications WITH Cause of Death (See Eligibility on the reverse side of this form):

$4.00 for each subsequent certification

$4.00

Additional Years to be Searched: Required only when exact year is not known

$2.00 for each additional year. The maximum additional year search fee is $ 50.00 regardless of the total number of years to be

$2.00

searched.

RUSH ORDERS (Optional): RUSH Fees are an additional $10.00.

If you desire RUSH service, mark the outside of your envelope “RUSH” (Processing time within our office for Rush

Service is 2-3 business days; routine processing time within our office is 4-6 business days.)

Check here for RUSH Order

TOTAL AMOUNT ENCLOSED: Check or Money Order Payable to: Vital Statistics. (DO NOT SEND CASH)

ENCLOSE COPY OF VALID PHOTO IDENTIFICATION IF

International payments should be made by Cashiers Check or Money Order in U. S. Dollars.

CAUSE OF DEATH REQUESTED OR YOUR ORDER WILL

Florida Law imposes an additional service charge of $15.00 for dishonored checks.

NOT BE COMPLETED

SECTION C – APPLICANT/MAILING INFORMATION

Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382, Florida Statutes, or on any

application or affidavit, or who obtains confidential information from any Vital Record under false or fraudulent purposes, commits a felony of the third degree,

punishable as provided in Chapter 775, Florida Statutes.

FIRST, MIDDLE, LAST (INCLUDING ANY SUFFIX)

Applicant Signature

Applicant’s Name

TYPE OR PRINT

LICENSE/BAR NUMBER

NAME OF PERSON YOU ARE REPRESENTING

If Funeral Director OR Attorney listed as Applicant and

requesting Cause of Death Information

If requesting cause of death, state your relationship (OR if a

RELATIONSHIP TO DECEDENT

funeral director or an attorney, the relationship of the person you