Form Ccr Vital 02 - Application For Certified Copy Of Death Record - 2013
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1
2
3MARK A. LUNN
VENTURA COUNTY CLERK AND RECORDER
APPLICATION FOR CERTIFIED COPY OF DEATH RECORD
In an attempt to stop the illegal use of vital records, and as part of statewide efforts to reduce identity theft, a new law (effective July 1, 2003)
changed the way certified copies of death certificates are issued. Certified Copies to establish the identity of a registrant can be issued only
to authorized individuals, as indicated below. All others will be issued Certified Informational Copies that are not valid to establish identity.
Fees: $16 per copy (payable to the Ventura County Clerk and Recorder).
Please indicate the type of certified copy you are requesting:
I would like a Certified Copy. This copy will establish the identity
I would like a Certified Informational Copy. This document
of the registrant. (To receive a Certified Copy you must indicate
will be printed with a legend on the face of the document
your relationship to the registrant by selecting from the list below
that states, “INFORMATIONAL, NOT A VALID
AND complete the attached Sworn Statement declaring that you
DOCUMENT TO ESTABLISH IDENTITY”.
are eligible to receive the Certified Copy. Your signature on the
(A sworn statement does not need to be provided.)
Sworn Statement must be acknowledged by a Notary Public if the
application is submitted by mail.)
□
□
Identification of applicant verified
Applicant had no identification
To receive a Certified Copy I am:
A parent or legal guardian of the registrant (person listed on the certificate).
A party entitled to receive the record as a result of a court order.
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business. (Companies representing a government agency must provide authorization from the government agency.)
A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant.
An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a court
to act on behalf of the registrant or the registrant’s estate. (If you are requesting a Certified Copy under a power of attorney, please
include a copy of the power of attorney with this application form.)
An agent or employee of a funeral establishment who acts within the course and scope of his or her employment and who orders certified
copies of a death certificate on behalf of any individual specified in paragraphs (1) to (5), inclusive, of subdivision (a) of Section 7100.
DO NOT complete the rest of this form before reading the detailed instructions on Page 3.
APPLICANT INFORMATION
(PLEASE PRINT OR TYPE)
Printed Name and Signature of Person Completing Application
Today’s Date
Telephone Number – Area Code First
(
)
Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Amount Enclosed
Purpose of Request
Mailing Address for Copies, if Different From Above
City
State
ZIP Code
DECEDENT INFORMATION
(PLEASE PRINT OR TYPE)
Name of Decedent – First (Given)
Middle
Last (Family)
Sex
Place of Death – County
Place of Birth
Date of Birth
Place of Death – City or Town
Date of Death – Month, Day, Year (Or Period of Years to be Searched)
Social Security Number
Mother’s Maiden Name
Name of Spouse (Husband or Wife of Decedent)
DEATH
CCR Vital 02 (Rev. 01/2013)
Page 1 of 3
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