Application For Certified Copy Of Death Record Form - State Of California
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2APPLICATION FOR CERTIFIED COPY OF DEATH RECORD
Effective July 1, 2003, California Health and Safety Code Section 103526 changed the way certified copies of death certificates are issued.
Certified Copies to establish the identity of a registrant can be issued only to authorized individuals, as indicated below. All others will be
issued Certified Informational Copies that are not valid to establish identity.
Fees: $21.00 per copy (payable to the Butte County Clerk-Recorder).
Please indicate the type of certified copy you are requesting:
I would like a Certified Copy. This copy will establish the identity
I would like a Certified Informational Copy. This copy
of the registrant. (To receive a Certified Copy you must indicate
will be printed with a legend on the face of the document
your relationship to the registrant by selecting from the list below
that states, “INFORMATIONAL, NOT A VALID
AND complete the attached Sworn Statement declaring that you
DOCUMENT TO ESTABLISH IDENTITY”.
are eligible to receive the Certified Copy. The Sworn Statement
(A sworn statement does not need to be provided.)
must be notarized if the application is submitted by mail unless
you are a law enforcement or local or state governmental
agency.)
NOTE: Both documents are certified copies of the original document on file with our office. With the exception of the legend, the
documents contain the exact same information.
To receive a Certified Copy I am:
A parent or legal guardian of the registrant (person listed on the certificate).
A party entitled to receive the record as a result of a court order.
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business. (Companies representing a government agency must provide authorization from the government agency.)
A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant.
An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a court
to act on behalf of the registrant or the registrant’s estate. (If you are requesting a Certified Copy under a power of attorney, please
include a copy of the power of attorney with this application form.)
Any agent or employee of a funeral establishment who acts within the course and scope of his or her employment and who orders
certified copies of a death certificate on behalf of an individual specified in paragraphs (1) to (5), inclusive, of subdivision (a) of Section
7100 of the Health and Safety Code.
APPLICANT INFORMATION
(PLEASE PRINT OR TYPE)
Printed Name and Signature of Person Completing Application
Today’s Date
Telephone Number – Area Code First
(
)
Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Amount Enclosed
Purpose of Request
Mailing Address for Copies, if Different From Above
City
State
ZIP Code
DECEDENT INFORMATION (PLEASE PRINT OR TYPE)
Name of Decedent – Last
First
Middle
Sex
City of Death
County of Death
Date of Birth – MM/DD/CCYY
State of Birth
Social Security Number
Date of Death – MM/DD/CCYY (Or Period of Years to be Searched)
Mother’s Maiden Name
Name of Spouse – Husband or Wife of Decedent (Last, First, Middle)
(Revised 1/1/15)
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