Form H105.102 - Application For Certified Copy Of Death Record printable pdf download

Application for Certified Copy of Death Record

H105.102 REV 05/2015

DEATH

Pennsylvania Department of Health ♦ Division of Vital Records

PART 1:

By my signature below, I state I am the person whom I represent myself to be herein, and I affirm the information

within this form is complete and accurate and made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification

to authorities. In addition, I acknowledge that misstating my identity or assuming the identity of another person may subject me

to misdemeanor or felony criminal penalties for identity theft pursuant to 18 Pa.C.S. §4120 or other sections of the Pennsylvania

Crimes Code. (Note: Signature must agree with name listed in Parts 2 and 5 of this form.)

Signature of person making request (Do not print): ___________________________________________________________________

Signature required on ALL requests. Must be 18 years of age or older to apply. If under 18, immediate family member must request record.

PART 2:

PRINT or TYPE name of individual requesting record and his/her current mailing address.

(If attorney, please indicate representation)

Relationship to Person

Name: ___________________________________________________Named on Record: _______________________________________

Address:_________________________________________________________________________________________________________

City:__________________________________________________________________ State: __________________ Zip:____________

Daytime phone number: (______) _______ - _________

E-mail Address:_________________________________________

Intended Use of Certified Copy:

(Documentation required verifying your direct interest if you are not related to the decedent or are not the attorney

 Social Security/Benefits

 Insurance

 Financial Institution

 Genealogy

 Estate Settlement

for the estate)

 Other (List reason: __________________________________

)

PART 3:

PRINT or TYPE information below regarding person who died:

Number of copies: ________

Name at Death: _________________________________________________________________

 Male

 Female

Sex:

Date of Death: _______________________________________________ Place of Death: _____________________________________

(Month/Day/Year - Records available from 1906 to the present)

(County)

(City/Boro/Twp. in Pennsylvania)

Social Security #:____________________________________ Age at Time of Death: _________ Date of Birth: ___________________

Mother’s or Parent A’s Name: ______________________________________________________________________________________

(First)

(Middle)

(Last prior to marriage)

(Current last)

Father’s or Parent B’s Name: ______________________________________________________________________________________

(First)

(Middle)

(Last prior to marriage)

(Current last)

Funeral Director: __________________________________________________________________________________________________

PART 4:

DEATH: $9.00 each.

If fee is required, make check/money order payable to: VITAL RECORDS.

Fees may be waived for individuals and their dependents who served or are currently serving in the Armed Forces (complete the following):

Armed Forces Member’s Name: ________________________________________Service Number:_______________________________

Relationship to Armed Forces Member: _________________________Rank and Branch of Service:________________________________

PART 5:

VALID GOVERNMENT ISSUED PHOTO ID REQUIRED

♦ Individual requesting record must include a legible copy of his/her valid government issued photo ID that verifies name and

mailing address as listed in Part 2 above.

♦ Examples: State issued driver’s license or non-driver photo ID (if address has been changed, include copy of update card).

♦ If possible, enlarge photo ID on copier by at least 150% (copies of ID will be shredded upon review).

♦ If acceptable ID not available, visit our website at

for further information.

Mail with self-addressed, stamped envelope to:

You are welcome to visit one of our offices in

Division of Vital Records

the following cities in Pennsylvania

ATTN: Death Unit

♦ Erie: 1910 West 26

Street

♦ Harrisburg: Forum Place

PO Box 1528

New Castle, PA 16103

555 Walnut St., 1

Floor

♦ New Castle: Central Bldg. (Room 401)

Print or type name and address in the space provided below

101 South Mercer Street

(Must agree with name and current address in Part 2 and ID documentation):

♦ Philadelphia: 110 North 8

Street

(Suite 108)

Name

♦ Pittsburgh: 411 7

Avenue

(Suite 360)

Street

♦ Scranton: Scranton State Office Bldg.

(Room 112), 100 Lackawanna Avenue

City, State, Zip Code

For

EXPEDITED ON-LINE ORDERING

or additional information, visit our website:

Form H105.102 - Application For Certified Copy Of Death Record

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