Form Acr 406 - Application For Certified Copy Or Search Of A Death Record - 2014 Page 2
Download a blank fillable Form Acr 406 - Application For Certified Copy Or Search Of A Death Record - 2014 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Acr 406 - Application For Certified Copy Or Search Of A Death Record - 2014 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2INSTRUCTIONS TO COMPLETE APPLICATION FOR A
CERTIFIED COPY OR SEARCH OF A DEATH RECORD
If no record of the death is found, pursuant to Health and Safety Code 103650, the $21.00 fee will be
retained for searching and a Certificate of No Record will be issued.
PLEASE PRINT IN BLACK OR BLUE INK
Death Certificate Information:
1
Give all the information you have available for the identification of the record.
Riverside County only has records of deaths that occurred in Riverside County. For all other death records you must
contact the county in which the death occurred or contact the Department of Health Services, Office of Vital Records-M.S.
5103, P.O. Box 997410, Sacramento, CA 95899-7410. Phone number: (916) 445-2684.
Section 103526 of the California Health and Safety Code restricts who is allowed to obtain an authorized certified copy of a
2
death record. You must be one of the authorized persons described in the six sentences in section 3 on the front of this
application.
Those who are not authorized will receive an INFORMATIONAL CERTIFIED COPY with the words “INFORMATIONAL,
NOT A VALID DOCUMENT TO ESTABLISH IDENTITY” imprinted across the face of the copy.
An AUTHORIZED CERTIFIED COPY of a death record may be required to obtain death benefits, claim insurance
proceeds, notify social security and obtain other services related to an individual’s identity.
If you are requesting an informational copy you do not need to complete the sworn statement at the bottom of this
application.
If you are requesting an authorized certified copy of a death record, please check the box that allows you to obtain the
3
authorized certified copy.
Print or type name of person ordering copy.
4
Print or type address of person ordering copy.
A governmental issued picture I.D. is required if ordering in-person. Please have it ready.
5
Section 103526 of the California Health and Safety Code requires anyone requesting an authorized certified copy of a
death record to complete and sign the sworn statement on the front of this application.
Please print your name in the
space provided and complete the space for the date and location for when and where you sign this statement.
BY MAIL:
When submitting multiple certificate requests at the same time, all requests must contain the completed sworn
statement on the front of this application but only one request would require the notary statement. Any member of a law
enforcement agency or a representative of a state or local government agency, as provided by law, who applies for a birth
certificate conducting official business, is NOT required to provide the notarized statement below.
(a) For an AUTHORIZED copy, complete the sworn statement in front of a notary public.
(b) For an INFORMATIONAL copy, the sworn statement in section 5 on the front of this application and the notarized statement
below are NOT required.
Send the application and a check payable to Riverside County Recorder, P.O. Box 751, Riverside, CA 92502-0751
Certificate of Acknowledgment
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 document.
STATE OF CALIFORNIA
}
COUNTY OF _______________________}
On ______________ before me, _____________________________________________________, personally appeared
(Date)
(Print Name and Title of Official)
_______________________________________________________________________________________________ ,
(
)
Insert name of person being acknowledged
who proved to me on the basis of satisfactory 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
(Seal)
(Officer signature)
ACR 406 (Rev. 11/2014)
Available in Alternate Formats
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal