Death Certificate Application Form - White
Download a blank fillable Death Certificate Application Form - White in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Death Certificate Application Form - White with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Death Certificate Application
Division of Vital Records
th
Phone: (405) 271-4040
1000 NE 10
Street
Walk-in Hours: Mon-Fri 8:30-4:00
Oklahoma City, OK 73117
Requirements:
1) Section 1 must be completed in full.
2) Section 2 is optional but may provide additional information to locate the record
3) Enclose a copy of a current legal photo ID (See back for list of acceptable IDs)
4) Enclose appropriate fees
5) Person applying to receive a death certificate must sign below
6) If submitting by mail, enclose a self-addressed stamped envelope
Section 1: REQUIRED INFORMATION: Complete in full
Check box if death was stillbirth or fetal death
Full Name of Deceased: _____________________
________________________
______________________________________
First
Middle
Last
Date of Death: _____ / ______ / _____
Place of Death _____________________________________________, OKLAHOMA
Month
Day
Year
City and/or County
Applicant Information:
Name ___________________________________________
Daytime Telephone Number: (______) _______ - __________
Street Address ____________________________________________Apt _______
City, State and Zip ______________________________________
Purpose for which the death certificate is needed:
Estate Settlement
Genealogy
Other, specify: ___________________________________
By signing below, I declare that all information provided on this application is true and correct.
Signature: ______________________________________________________________
Date Signed: _____________________________
(Application will not be processed without the signature of the applicant)
Section 2: OPTIONAL INFORMATION: May assist in locating a record
___________________________
Social Security Number: _____-_____-_____
Gender:
Spouse Name:
Female
Male
_________________________________________________________________________
Funeral Home Name and Address:
Date of Birth: _____ / ______ / _____
Place of Birth: _______________________________________, ___________________
Month
Day
Year
City and/or County
State
Father’s Name and Birthplace: _____________________________________________________________________________________
Mother’s Name and Birthplace: _____________________________________________________________________________________
Fees
A fee is to be paid for a search of the files or records, even when no copy is available. Search fees are non-transferable and non-refundable.
_______ Number of certified copies requested ($15 per copy which includes a search fee)
_______ Amendment Fee ($35 Required to amend non-medical certification items. Includes 1 certified copy.)
_______ Total Amount enclosed
Make checks payable to OSDH. Do not send cash by mail.
Print Form
Mailing address: Division of Vital Records, PO Box 53551, Oklahoma City, OK 73152
OFFICE USE ONLY
Mail
Issuance
Front Desk
Reviewed by: ____________________
Copies Issued: ____________________________
Clerk: ______________________________
Date: ________ / _______ / ________
Date Completed: _______ / _______ / ________
Date: ______________________________
Fees Enclosed: $_________________
Issued by: ________________________________
Fees Paid: $ ________________________
MO
Fees Due: $ _____________________
Other: ____________________________________
Fee Type:
Check
Cash
ID Enclosed: _____________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business