Application For Unrestricted Certified Copy Of A Death Record Form - Alameda County Page 2
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1
2APPLICATION FOR UNRESTRICTED CERTIFIED COPY
OF A DEATH RECORD-$23.00 PER COPY in ALAMEDA COUNTY
1
Death Certificate Information (Deceased)
Number of copies requested: __________________
Name of Deceased:_____________________________________________________________________________________
Last
First
Date of Death: _____________________________________
City of Death: _________________________________
Month/Day/Year
2
Applicant Information
(If ordered online) Confirmation #: ___________________
GF
Last Name: ______________________________________
First Name:_________________________________________
GF
Home Address:__________________________________________________________________________________________
(P.O. Box not acceptable) Number and Street (APT #)
City
State
Zip Code
Shipping Address: _______________________________________________________________________________________
(If Different than home)
Number and Street
City
State
Zip Code
Telephone Number: _(_____)___________________________Email Address: _______________________________________
To obtain an Unrestricted Certified Copy the applicant must be authorized under section 103526 of the Health and Safety Code.
3
Please review and check the appropriate box below:
The registrant or a parent or legal guardian of the registrant. (Legal guardian must provide documentation.)
A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption agency seeking the
birth record in order to comply with the requirements of Section 3140 or 7603 of the California Family Code. (Please include
a copy of the 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. (Photo identification or a request on the agency’s letterhead.)
A child, grandparent, grandchild, brother or sister, 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. (Please include a copy of the power of
attorney; documentation identifying you as executor or supporting documentation.)
An 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 any individual specified in paragraphs (1) to (5), inclusive, of
.
subdivision (a) of Section 7100
4
I, _______________________________, swear under penalty of perjury that I am an authorized person, as defined in California
(Print Applicant’s Name)
Health and Safety Code Section 103526 (c), and am eligible to receive a certified copy of the death record identified on this
application form. Sworn this _____________________ day of _________________________________, 20________________,
at ____________________________________________________
Signature: ___________________________________
(City and State)
Acknowledgment
5
A notary public or other officer completing this certificate verifies only the
State of ______________________
identity of the individual who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or validity of that document.
County of ____________________
On ____________________ before me, ____________________________________________________, personally appeared
(name and title of the officer)
____________________________________ who proved to me on the basis of satisfactory evidence to be the person whose
name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized
capacity, and that by his/her signature on the instrument the person, or the entity on behalf of which the person 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.
WITNESS my hand and official seal:
________________________________________
Signature of Notary Public
(Notary Seal)
J:\RECDOCS\New Clerk-Recorder Form Inventory\2015\Vitals & GB
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