Request For A Death Certificate Template - State Of California
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1
2D
R
EATH
ECORD
Instructions / Acknowledgment
Instructions for completing application form on reverse side:
1. Use separate application form for each different name on death record.
2. Complete the “Death Record” and “Applicant Information” sections, indicating if you want an Authorized Certified
copy or an Informational copy of the record.
NOTE: If the information on the request is incomplete or inaccurate, it may be impossible to locate the record.
3. Please read and sign the Sworn Statement ONLY if requesting an Authorized Certified copy.
4. If submitting request(s) by mail or by fax, the Sworn Statement MUST be signed in the presence of a Notary Public.
NOTE: Only one notarized sworn statement is required for multiple certificates for each name requested at the same
time; the application with the notarized sworn statement must include the name of each individual whose certificate you
wish to obtain and your relationship to that individual. (Law enforcement, funeral establishments and local and state
governmental agencies are exempt from the notary requirement.)
5. Submit the appropriate fee for each certified copy requested, along with $1.00 for return postage or a Self-Addressed
Stamped Envelope. If mailing application(s), please make all checks or money orders payable to YOLO COUNTY
CLERK/RECORDER. For facsimile requests, please fax application and credit card form, or after faxing, you
can call and give credit card information.
If no record of the death is found, the fee will be retained for searching,
as required by statue, and a Certificate of Search indicating no record was found will be mailed to you.
MAIL COMPLETED APPLICATION WITH FEE
TO:
(S)
Yolo County Clerk/Recorder
PO Box 1130
Woodland, CA 95776-1130
Office (530) 666-8130
Fax (530) 666-8109
CERTIFICATE OF ACKNOWLEDGMENT
(for AUTHORIZED certified copies only, if mailed or faxed)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate
is attached, and not the truthfulness, accuracy, or validity of that documents.
State of ______________________________)
§
)
County of ___________________________)
On ______________________________, before me _____________________________________________________________________________,
(date)
(name and title of officer)
personally appeared ___________________________________________________________________ who proved to me on the basis of satisfactory
(name of person signing)
evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they
executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or
the entity upon behalf of which the person(s) 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 ______________________________________________________
(officer)
(NOTARY SEAL)
5/1/2016
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