Form 523 - Application For Certified Copy Of Death Certificate 1993

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MISSISSIPPI VITAL RECORDS
P.O. Box 1700
Jackson, MS 39215-1700
APPLICATION FOR CERTIFIED COPY OF DEATH CERTIFICATE
INFORMATION
1. Only deaths recorded after November 1, 1912 are on file.
2. The death certificate is the most important legal document in the settlement of the estate and insurance. It is important that the information on the
certificate is correct. When you receive copies of the death certificate, check particularly spelling of names and that dates are correct.
3. If there are incorrect items on the certificate and the death occurred less than one year ago, please notify the funeral director who filed the certificate.
4. If there are incorrect items on the certificate and the death occurred more than one year ago, a court order may be required.
Please contact Vital Records at the above address for additional information.
5. The fee for a certified copy of a death certificate is $10.00. Each additional copy ordered at the same time is $2.00.
6. A five year search of our records will be made. If the record is not on file, a search fee of $6.00 will be retained.
INSTRUCTIONS
1. Complete the information sections of this form. PLEASE PRINT.
2. The application must be signed.
3. PAYMENT:
Out-of-state: Remit a bank or postal money order or a bank cashier’s check in the correct amount made payable to Mississippi State Department of
Health.
Mississippi Resident: In addition to the above methods of payment, personal checks are acceptable if drawn on a Mississippi bank; make payable to
Mississippi State Department of Health.
We accept no responsibility for cash sent through the mail. Request for adjustments or refunds will be honored only if received within six months of
application.
4. Send completed application, appropriate fee and self-addressed stamped legal size envelope to the address at the top of this form.
INFORMATION ABOUT PERSON WHOSE DEATH CERTIFICATE IS REQUESTED (Type or Print)
FIRST NAME
MIDDLE NAME
LAST NAME
1. FULL NAME
OF DECEASED
MONTH
DAY
YEAR
2. DATE OF
DEATH
COUNTY
CITY OR TOWN
STATE
3. PLACE OF
DEATH
4. Sex
5. Race
6. Age at Death
7. State File Number (if known)
8. Name of Father
9. Name of Mother
10. FUNERAL
Name
Address
DIRECTOR
11. PURPOSE FOR WHICH CERTIFIED COPY IS TO BE USED
NO. OF COPIES. . . . . . . . . . . . . . . . ______________
12. RELATIONSHIP OR INTEREST OF PERSON REQUESTING CERTIFICATE
Pursuant to Section 41-57-2 of the Mississippi Code of 1972, Annotated, and as defined by
VETERAN’S SERVICE
Mississippi State Board of Health Rules and Regulations, I hereby certify that I have a
OR VA CLAIM NO:
legitimate and tangible interest in the death record requested. I understand that obtaining a
record under false pretenses may subject me to the penalty as described in Section 41-57-27
____________________
of the Mississippi Code of 1972, Annotated.
13. SIGNATURE OF APPLICANT
TOTAL. . . . . . . . . . . . . . . . . . . . . . . ______________
14. DATE SIGNED
FEE SUBMITTED . . . . . . . . . . . . $ ______________
PRINT OR TYPE YOUR MAILING ADDRESS HERE
Name
15.
Street or Route
16.
APT. NO.
City or Town
17.
State, ZIP Code
Mississippi State Department of Health
Revised 9-93
Form No. 523

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