Death Certificate Order Form - Lane County Vital Records

Death Certificate Order Form

MAIL TO: LANE COUNTY VITAL RECORDS

151 W. 7th Ave., Rm. 520, Eugene, OR 97401

Monday – Friday 9:00 a.m. – 4:30 p.m.

Phone (541) 682-4045 Fax (541) 682-9825

This form is to order a death certificate at Lane County for the first six months after the date of death.

After six months from date of death, we can no longer issue certificates and you will need to order from the Oregon State Vital Records

office located in Portland, Oregon at (971) 673-1190. If you have any questions, please do not hesitate to call our office.

Checks or Money orders payable to: Lane County Vital Records

DO NOT MAIL CASH

$25 first record / $20 each additional copy of the same record ordered at the same time

________ Certified, Long Form with Cause of Death

________ Certified, Short Form/Fact of Death

Quantity

Quantity (

for Property Transfer/Title Change in Oregon)

__________________________________________________________________________

(1) Name of Deceased:

First Name

Full Middle

Full Last

_________________________

______________________________________

(2) Date of Death:

(3) City of Death:

Month / Day / Year

____________________________

____________________________

(4) Mortuary:

(5) Your Relationship to Deceased:

*

______________________________________________________________

(6)

Name of Person Requesting Record:

*

Person requesting record by mail: Attach photocopy of current, valid ID or legal representative document.

____________________________________________________________________________

(7) Mailing Address:

_____________________________

_________________________

___________________

City:

State:

Zip Code:

______________________________________(

(______)____________________

(8) Signature:

9) Phone Number:

In Accordance with law – ORS 432.120, access to death records is restricted for 100 years to registrant, family members, legal representatives, government agencies and persons

licensed or registered under ORS 703.430. Legal guardians must enclose a copy of the legal document. If you are not eligible, enclose a written permission note with a notarized

signature of an eligible person. Providing false information is a felony under ORS 432.900.

OFFICE usE Only - DO nOt wrItE bElOw thIs lInE

_____________________

____ /____ /____

_____________

OR DL:

Exp. Date

Pmt Type: Cash / CC / Check-MO#

______________________

____ /____ /____

_______________

Passport or Other ID:

Exp. Date

Today’s Date:

__________________-_______

__________________-_______

Exchange

Returned Cert #s:

Certificate Number(s)

________________

________________________________

_____________

Case #

Order #

Amount Received: $