Death Certificate Request Form
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1City of Boston
Registry Division
REQUEST FOR A CERTIFIED COPY OF A DEATH CERTIFICATE
WHAT TO INCLUDE WITH YOUR REQUEST:
1. Request:
Completed Request Form including original ink signature.
2. Payment:
Certificates cost $14.00 per copy when ordered through the mail. Requests for records prior to 1870 require an
additional $10 research fee on a separate check, and this fee is not refundable.
Payment may be made in check or money order payable to "City of Boston."
3. Return:
Please include a self-addressed stamped envelope.
Print out this form and return/mail to:
Registry Division - Death
One City Hall Square, Room 213
Boston, MA 02201
*Please Take Note of Restrictions and Special Circumstances
Number of copies requested: _______________
Full name of person on the record of death
_______________________
_________________
_________________________________ / ______________________
First
Middle
Last
Maiden Name
if applicable
Date of Death: ________________ __________ ______________
Age at Time of Death: _________
Month
Day
Year
Exact Location of Death:
______________________________________
________________________________________
Hospital, Nursing Home, etc.
City or Town
*Address where they resided at the time of their death: _________________________________________________
*Spouses Name: __________________________________________________________________________
*Parents’ Name: ___________________________________________________________________________
*These items are not required, but will assist in finding the record being requested.
Person Requesting the Certificate: ________________________________________________________________________
Relationship of requester to subject(s) named on record: _______________________________________________________
Return Mailing Address:
________________________________________________________________________
Signature of Requester:
__________________________________________________________
Daytime telephone number
______- ______-_________ Email: _____________________________
____ I do not want the Certified Copy of this death certificate if the Cause of Death is still Pending.
A record may be pending if the Medical Examiner conducted an autopsy and the final results may not have been determined
right away. Sometimes insurance, banks, and others do not accept a Certified Copy of a death certificate if it is still pending.
*TAKE NOTE
If you are sending multiple requests for birth, death, or marriage certificates please send individual requests.
If we do not have the record we will call and/or return the check in the self-addressed stamped envelope that you have included with
your request.
The Registry Division is OPEN weekdays from 9AM-4PM except Holidays
Website:
Office Phone: 617-635-4175
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