Mail Application For Certified Copy Of Death Certificate Form - San Joaquin County Public Health Services
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2San Joaquin County Public Health Services
Mail Application for Certified Copy of Death Certificate
Effective July 1, 2003 California law permits only authorized individuals to receive authorized certified copies of death
records required for formal legal purposes such as insurance and other benefits. If you are requesting an authorized
certified copy, complete all application sections and submit with the notarized statement as described in section 4.
An informational certified copy may be obtained by any person but cannot be used to establish formal identity. If you
are requesting an informational certified copy, complete sections 1 and 2 only and submit the application. A notarized
statement is not required for an informational only copy.
The health department furnishes certified copies for deaths that
were registered during the current and past calendar year only.
Submit this application form with the appropriate fees to:
Public Health Services – Vital Records Unit
PO Box 2009 Stockton, CA 95201-2009
Permanent records are kept at the County Recorder’s Office at :
nd
44 N. San Joaquin St., 2
floor Ste. 260
Stockton, CA 95202
Certificate Type Requested: ___Authorized Certified
___Informational Only
Number of Certificates ___ Amended___Pending___VA__
Date Requested_________
1. Decedent/Registrant Information
Name _________________________________________ Date of Death ___/____/___
Place of Death ______________________
2. Requestor Information
Requested By:___________________________________
Mail To: ________________________________________
Mail Address_________________________ ______________ _____ __________
Number and Street
City
State
Zip Code
3. Authorized Individual Information – Complete this section if requesting authorized
certified copy. Specify which category of authorized individual you are:
A parent or legal guardian of the registrant.
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.
A child, grandparent, sibling, spouse, or domestic partner of the registrant.
An attorney representing the registrant or the registrant’s estate; a person or
agency empowered by statute or appointed by a court to act on behalf of the registrant or
registrant’s estate.
A funeral director ordering certified copies of a death certificate on behalf of an
individual specified in paragraphs (1) to (5), inclusive, of subdivision (a) of Section 17100 of
the California Health and Safety Code.
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