Request For A Death Certificate Template - State Of California (Page 2 of 2) in pdf

COUNTY OF YOLO

For official use only:

Certificate #: __________________________________

CLERK/RECORDER

Gov’t agency ____________ Clerk initials __________

Jesse Salinas, County

Clerk/Recorder

CERTIFIED COPY

EATH

ECORD

Today’s Date: ________________________

Number of copies requested: ________

$21.00

Death Record

per copy

Death Record Information:

Name on

Certificate__________________________________________________________________________________________

First

Middle

Last

Date of

______/_______/______

Place of

____________________________________________________

Death

Month/Day/Year

City

County

State

Father’s Name: _____________________________________________________________________________________

First

Middle

Last

Mother’s Maiden Name: ______________________________________________________________________________

First

Middle

Last

Mark Appropriate Boxes

(See H&S Code 103526 below)

Authorized CERTIFIED COPY of the record

INFORMATIONAL COPY of the record

(Sworn statement required)

(Sworn statement not required)

“INFORMATIONAL COPIES ARE NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.”

The California H&S Code 103526, permits only persons as defined below to receive Authorized certified copies of Birth, Death and

Marriage records. Those who are not authorized by law will receive a certified copy stamped: “INFORMATIONAL, NOT A VALID

DOCUMENT TO ESTABLISH IDENTITY.”

I am:

The registrant or a parent or legal guardian of the registrant.

A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption agency seeking the death record in order to

comply with the requirements of Section 3140 or 7603 of the Family Code.

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, grandchild, sibling, 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.

Any agent or employee of a funeral establishment acting within the scope of employment who orders certified copies of a death certificate on behalf

of any individual specific in paragraphs (1) to (5), inclusive, of subdivision (a) of Family Code Section 7100.

Applicant Information:

Name: ___________________________________

Telephone Number: (

) __________________________

(Print Name)

Address: __________________________________________________________________________________________

Number and Street

City

State

Zip Code

SWORN STATEMENT

(Not required for an INFORMATIONAL COPY)

I, _________________________________________________________, declare under penalty of perjury under the laws

(Printed Name)

of the State of California, that I am an authorized person, as defined in California H&S Code 103526 (c), and am eligible to

receive a certified copy of the death record of the above and/or attached individual(s):

Sworn on ____________________ /__________________________

___________________________________________________

(Date and Place)

(Signature)

Note: If submitting your order by mail or facsimile, please read instructions carefully.

5/1/2016

Request For A Death Certificate Template - State Of California Page 2

Related Articles

Related Categories