Application For Certified Copy Of Death Certificate
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1STATE OF WYOMING
APPLICATION FOR CERTIFIED
Purpose for Which Copy is needed
COPY OF DEATH CERTIFICATE
A request for a certified copy of a death certificate should
be submitted on this form along with the fee of $10.00 per
Signature of Person Requesting Certificate
copy. If the date of death is unknown, a searching fee of
$13.00 for every five years searched is charged, which
includes either a certified copy or verification of the record
X__________________________________
if one is found. A money order or a personalized check
Address of Applicant
from the person making the request should be made
payable to VITAL RECORDS SERVICES.
___________________________________
If a death record is not located, your fee will be retained as
a searching fee.
___________________________________
Enclosed is $_______for______certified copy/copies.
___________________________________
The fee listed above includes a surcharge for the Wyoming
Children’s Trust Fund used to establish programs for the
prevention of child abuse and neglect. Wyoming Statute
35-1-428 requires Vital Records Services to collect this
surcharge on all certified copies and search of the files.
PHOTOCOPY OF IDENTIFICATION
Full Name of Deceased
Written signature must be a permanent
Part of ID
First Name
________________________________
Middle Name ________________________________
Last Name
________________________________
Date of Death
_______/_______/_______
If certificates are to be mailed to a
different address, a Self Addressed
Place of Death
Stamped Envelope must be
enclosed.
City_________________ or County__________________
Name of Surviving Spouse
Mail your request to:
Vital Records Services
Relationship to Deceased (If funeral director or attorney,
Hathaway Building
state the relationship of the person for whom you are
Cheyenne, WY 82002
obtaining the copies. (i.e. Attorney for spouse.)
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