Application For Copies Of Death Certificate - City Of Bedford
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1Receipt No. ____________
CITY OF BEDFORD
Cash
____________
APPLICATION FOR
VITAL STATISTICS
Check No.
____________
CERTIFIED COPIES OF
2000 FOREST RIDGE
Money Order ____________
DEATH CERTIFICATE
MC/Visa ________________
BEDFORD, TX 76021-1895
Expiration ______________
817-952-2112
817-952-2397 fax
Control No. _____________
817-952-2211 alternate fax
THE FOLLOWING ARE THE ONLY
RECOGNIZED QUALIFIED APPLICANTS
DEATH
# Requested
Please check your relationship to decedent:
___1_ Certified Copy X $21.00 = $21.00
_____ Extra Copies of
____ Spouse
____ Child
Same Record X $4.00
= _____
____ Parent
____ Grandchild
VA ____
TOTAL ENCLOSED = _____
____ Grandparent
____ Legal Rep/Guardian
____ Stepparent
____ Informant
____ Sibling
____ Funeral Home
PLEASE PRINT
Registrar File # _______________
See Reverse Side for Instructions
Burial Transit Permit # ________
Full Name of Person
1. First Name
Middle Name
Last Name
on Record
Date of Death
2. Month
Date
Year
3. Sex
Place of Death
4. City or Town
County
State
BEDFORD
TARRANT
TEXAS
Full Name of
5. First Name
Middle Name
Last Name
Father
Full Maiden Name
6. First Name
Middle Name
Maiden Name
of Mother
7.
.
ADDITIONAL IDENTIFYING INFORMATION FOR DEATH CERTIFICATE
________________________________________________________________
SOCIAL SECURITY NUMBER OF DECEASED
_______________________________
. _____________________________________
BIRTH DATE
BIRTH PLACE, ETC
8.
_________________________________________
9.
(_____)________________
APPLICANT’S NAME:
PHONE #
8:00 – 5:00
10.
__________________________________________________________________________________
MAILING ADDRESS:
STREET ADDRESS
CITY
STATE
ZIP
11.
_____________________________________________________________
RELATIONSHIP TO PERSON NAMED IN ITEM 1:
12.
_____________________________________________________________
PURPOSE FOR OBTAINING THIS RECORD:
WARNING: THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2-10
YEARS IN PRISON AND A FINE OF UP TO $10,000. {HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003}
_____________________________________
____________________________
SIGNATURE OF APPLICANT
DATE
IDENTIFICATION TYPE ________________________
NUMBER _________________________
.
Drivers License, I.D. Card, etc
on Drivers License, I.D. Card, etc.
Death records are confidential for 25 years: therefore, issuance is restricted to qualified applicants. Please attach a photocopy of ID to
application. Administrative rules require that on restricted records, all identifying information (items 1-6), relationship (item 11), and purpose
(item 12) be provided in order to issue the record.
Fees are subject to change without notice. (Call 817-952-2112 for fee verification.)
Office Use Only
Issued by:
______________
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