Form Hc1238gc - Death Certificate Application Page 2
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1
2Affidavit of Identity to Obtain Certified
Death Certificate
(In order to use this form the identifier must have known applicant for at least 2 years.
MN rules 4601.2600 sub 6)
"This page only needs to be completed if the applicant's signature is not notarized on the first page."
Identifier Information
NAME:
First
Middle
Last
ADDRESS:
City
State
Zip
Phone Number
:
DATE OF BIRTH:
DD/MM/YYYY
Relationship
to the Applicant:
I have known
, the Applicant, for
years and solemnly
swear or affirm that he/she is the person presenting this Application for a Certified Death Certificate.
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SIGNATURE:
DATE:
(Sign in the presence of the registrar and present an acceptable document of identity)
When requesting a certified or uncertified copy, or to view/verify information of a birth, death, or marriage record,
specific information is required and is defined as the correct date of the event and the correct name of the registrant.
(Minn. Stat. §
144.226)
Lacking specific information incurs a “search time” fee of $20 per hour ($10 minimum) in
addition to the cost of the copy.
If the Identifier cannot accompany the Applicant to the registrar’s office, the Identifier’s signature
MUST be notarized.
Subscribed and sworn before me this ____day of_______, 20___
(seal)
____________________________________________________
Notary
My Commission expires:
_
______________________________
Administrative use only:
ID viewed – Type
No.
Init.
HC1238GC (06/14)
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