Dh Form 434a - Affidavit Of Medical Amendment To Florida Certificate Of Death Page 2
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1
2INSTRUCTIONS FOR MEDICAL AMENDMENT TO FLORIDA CERTIFICATE OF DEATH
(TYPE IN PERMANENT BLACK INK)
.
Private Physicians - The attending or certifying physician may amend the cause of death
section of any Florida Certificate of Death showing their name(s) on the original Florida
Certificate of Death.
Medical Examiners - Only the Medical Examiner, with current jurisdiction, may amend the
cause of death on any Florida Certificate of Death (whether originally signed by a private
physician or previous Medical Examiner of the district) coming under their jurisdiction pursuant
to Chapter 406, Florida Statutes.
A detailed explanation must be given to justify why you are amending the death record.
Comments such as “Per family request” should not be included.
The signature of the certifying physician, or medical examiner, is required on 31a with the
current date on 31b.
Complete and sign the Affidavit of Medical Amendment to Florida Certificate of Death in the
presence of a notary public or other officer having official seal.
The notary section at the bottom of the form must include:
•
Signature of either the attending physician, or certifying physician, or Medical Examiner
•
The date signed by certifier (must be the same as the notary’s date)
•
Notary’s Signature
•
Notary’s date “subscribed and sworn to before me on” (must be the same as the
certifier’s date)
There is no fee required by the Office of Vital Statistics to amend a death record with regard to
cause of death information. However, if computer certified copies of the amended record are
desired, a fee of $5.00 for the first copy and $4.00 for each subsequent copy ordered at the
same time is required and can be submitted at the time the affidavit is filed with this office. If
book copies of the amended record are desired, a fee of $10.00 for the first copy and $4.00 for
each subsequent copy ordered at the same time is required and can be submitted at the time
the affidavit is filed with this office. If copies are ordered at a later date, the fee should be
directed to the address below and to the attention of client services.
PLEASE COMPLETE AND RETURN THIS FORM TO THE DEPARTMENT OF HEALTH:
Medical Classification
Bureau of Vital
Statistics..
1217 N Pearl Street (zip
32202)..
P.O. Box
210..
Jacksonville, Florida
32231-0042..
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