Form Ccr Vital 02 - Application For Certified Copy Of Death Record - 2013 Page 2

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SWORN STATEMENT

(*Required for certified copy of record. This sworn statement is not required when requesting

an Informational certified copy which is not valid to establish identity)

*Any member of a law enforcement agency or a representative of a state or local government agency, as provided

by law, who orders a copy of a record to which subdivision (a) applies in conducting official business is required to

complete the Sworn Statement, however, they may not be required to have their signature on the Sworn Statement

acknowledged by a Notary Public.

I, _________________________________, declare under penalty of perjury under the laws of the State of California,

(Printed Name)

that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a

certified copy of the death record of the following individual(s):

Name of the Person Listed on the Death Certificate

Your Relationship to the Person Listed on the Death Certificate

(The remaining information must be completed in the presence of a Notary Public or County Clerk and Recorder staff.)

Subscribed to this _______ day of ______________, 20___, at _________________________, ________________.

(Day)

(Month)

(City)

(State)

______________________________________________________

(Signature of person requesting certified copy)

Note: If submitting your order by mail or fax, you must have your signature on the Sworn Statement

acknowledged by a Notary Public using the Certificate of Acknowledgment below. If submitting your order in

person, you must sign this in the presence of the County Clerk and Recorder staff.

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

CERTIFICATE OF ACKNOWLEDGMENT

State of ____________________)

) ss

County of ___________________)

On ________________, before me, _______________________________________________________________, personally

(Insert your name and title)

appeared __________________________________________________________________________, who proved to me on the

basis of satisfactory evidence to be the person(s) whose name is/are subscribed to the within instrument and acknowledged to me

that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument

the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and

correct.