Application For A Certified Death Certificate

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State of Nevada
Division of Public and Behavioral Health, Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242
APPLICATION FOR A CERTIFIED DEATH CERTIFICATE COPY OR VERIFICATION
Number of Copies FEE FOR A CERTIFIED DEATH CERTIFICATE COPY
$20.00 per certificate
TYPE OF CERTIFICATE (Please check one type box below)
X
Certificate(s) to read as “Mother / Father”
Certificate(s) to read as “Parent / Parent”
VERIFICATION ONLY
X
Verifies the existence of a record with the State of Nevada and does not include a certified copy.
Search/Verification - $10.00 per search / verification
MAKE PAYMENT PAYABLE TO: Office of Vital Records. Checks, money orders and credit cards are accepted.
Please include the Authorization for Credit Card Use form when paying by credit card.
A COPY OF THE APPLICANT’S PHOTO IDENTIFICATION, PROOF OF RELATIONSHIP AND
FULL PAYMENT IS REQUIRED TO OBTAIN CERTIFICATE OR VERIFICATAION
Name of the Person on the Certificate:
First
Middle
Last
Date of Death
County of Death
Social Security Number
Parent’s First and Last Name
Parent’s First and Last Name
Last Name(s) Prior to First Marriage
Funeral Home / Mortuary in Charge of Arrangements
NRS 440.650 and NAC 440.070 requires the applicant to establish a direct relationship by blood or marriage, a
legal relationship or a need to facilitate a legal process to receive a certified copy of a record. Below, indicate
your relationship or your legal need for this record. Please provide proof such as a birth certificate or court order.
The request will be rejected if sufficient proof is not provided. Visit our website listed above for more
information regarding proof required.
Relationship and Reason for Request
Applicant’s Printed Name
Applicant’s Signature
Applicant’s Address
Applicant’s Phone Number
FOR OFFICE USE ONLY
Amount received: _______________________ Receipt number: _________________________
No. of copies issued: ______________________ Date: ______________________
(Rev.02/26/2016)

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