Application For Certified Copy Of Death Certificate Form January 2001

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STATE OF WYOMING

APPLICATION FOR CERTIFIED COPY OF DEATH CERTIFICATE

Certified copies are $9.00 each. If the date of death is unknown, a fee of $12.00 for every five years searched is

charged, which includes either a certified copy or verification of the record if one is found. A money order or a

personalized check from the person making the request should be made payable to VITAL RECORDS SERVICES.

Please enclose a self-addressed, stamped envelope with the application. Send to:

Vital Records Services

Hathaway Building

Cheyenne, WY 82002

(307) 777-7591

If a death record is not located, your fee will be retained as a searching fee.

Enclosed is $ ______________ for ____________ certified copy(ies).

Full Name of Deceased First

Middle Name

Last Name

Date of Death

Place of Death - City or County

Name of Surviving Spouse

Signature of Person Requesting Certificate

>

Relationship to Deceased (If funeral director or attorney, state the relationship of the person for whom you are obtaining copies. Ex: Attorney for spouse

Purpose for which copy is

needed

Address of applicant:

_______________________________________

_______________________________________

_______________________________________

If copies are to be mailed to an address different than above, please give us that mailing address:

_______________________________________

_______________________________________

_______________________________________

W.S. 35-1-428 requires Vital Records Services to collect a $5.00 surcharge on all certified copies and searches of the files to be deposited in the Wyoming Children's Trust Fund. This surcharge is included

in the fee listed above. The fund is used to establish programs for the prevention of child abuse and neglect.

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