Form F-05280 - Wisconsin Death Certificate Application

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DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health

Wis. Stat. § 69.21

F-05280 (Rev. 11/2016)

Page 1 of 2

WISCONSIN DEATH CERTIFICATE APPLICATION

TYPE or PRINT.

(for Mail or In-Person Requests)

PENALTIES: Any person who illegally possesses any vital record with knowledge that the vital record has been illegally obtained is guilty of a Class I felony [a fine of not more than

$10,000 or imprisonment of not more than 3 years and 6 months, or both, per Wis. Stat. § 69.24(1)].

CURRENT NAME - First

MAIL TO NAME - First (if different)

Last

YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No.

MAIL TO ADDRESS (if different than street address)

Apt. No.

City

State

ZIP Code

City

State

ZIP Code

DAYTIME TELEPHONE NUMBER

EMAIL ADDRESS

(

)

PHOTO ID NUMBER

TYPE OF CURRENT VALID PHOTO ID

STATE OF ISSUANCE

EXPIRATION DATE

(See item 4, on page 2.)

Per Wis. Stat. § 69.20(1), a CERTIFIED copy of a death certificate is only available to those with a “direct and tangible interest." (A–D)

CHECK ONE box which indicates YOUR RELATIONSHIP to the PERSON NAMED on the death certificate.

I am a member of the immediate family of the person named on the death certificate.

Parent (My name is on the death certificate and my parental rights have not been terminated.)

Brother / Sister

Current Spouse

Child

Maternal Grandparent

Paternal Grandparent

Current Domestic Partner (registered in the Wis. Vital Records System)

I am the legal custodian or guardian of the person named on the death certificate.

I am a representative authorized by any person in category A or B, including an attorney.

Specify the person you represent: ____________________________________________________________________________________

I can demonstrate the death certificate is necessary for the determination or protection of a personal or property right.

Specify your interest: ______________________________________________________________________________________________

I am a direct descendent of the decedent and am requesting an uncertified copy of the death certificate.

None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity or legal purposes.)

NOTE: Stepparents, stepchildren, stepbrothers / stepsisters may only obtain certified copies as categories B–D.

PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:

FIRST COPY FEE …………………………………………………………………………………….………………..……

$ 20.00

___$20.00__

Fact of Death (without cause of death) (sufficient for most financial transactions)

Extended Fact of Death (with cause of death) (for insurance benefit claims)

EACH ADDITIONAL COPY (issued at the same time as the first copy)

$ 0.00

Fact of Death ………………………………………………..………….….. _____________________ X

$ 3.00

___________

Number of Additional Copies

$ 0.00

Extended Fact of Death …………………………………………….……… _____________________ X

$ 3.00

___________

Number of Additional Copies

$ 20.00

FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATION REQUESTS ARE NOT ACCEPTED.

TOTAL

___________

Submit your application materials and fee to: STATE VITAL RECORDS OFFICE / PO BOX 309 / MADISON, WI 53701-0309

Be sure to include:

completed form,

acceptable identification,

payment,

self-addressed, stamped, business-size envelope, and

any additional proof or authorization required

Make check or money order payable to: STATE OF WIS. VITAL RECORDS

NAME OF DECEDENT - First

Middle

Last

DATE OF DEATH

(MM/DD/YYYY)

PLACE OF DEATH – City, Village, or Township *

DECEDENT’S SOCIAL SECURITY NUMBER *

PLACE OF DEATH - County

DECEDENT’S AGE / BIRTHDATE *

DECEDENT’S OCCUPATION * NAME OF DECEDENT’S SPOUSE *

NAME OF DECEDENT’S PARENT *

I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies of

the requested death certificate in accordance with the categories listed above.

Date Signed (MM/DD/YYYY)

SIGNATURE (Applicant)



Important: Signature and payment are required for processing.

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