San Joaquin County Public Health Services

Mail Application for Certified Copy of Death Certificate

Effective July 1, 2003 California law permits only authorized individuals to receive authorized certified copies of death records required for formal legal purposes such as insurance and other benefits. If you are requesting an authorized certified copy, complete all application sections and submit with the notarized statement as described in section 4. 

 

An informational certified copy may be obtained by any person but cannot be used to establish formal identity. If you are requesting an informational certified copy, complete sections 1 and 2 only and submit the application. A notarized statement is not required for an informational only copy.

 

The health department furnishes certified copies for deaths that were registered during the current and past calendar year only.

Submit this application form with the appropriate fees to:

Public Health Services – Vital Records Unit

PO Box 2009 Stockton, CA 95201-2009

 

Permanent records are kept at the County Recorder’s Office at:

Permanent records are kept at the County Recorder’s Office at :
44 N. San Joaquin St., 2nd floor Ste. 260
Stockton, CA 95202

www.sjgov.org/Recorder/Vital.htm

 

Certificate Type Requested: ___Authorized Certified            ___Informational Only

 

Number of Certificates _____       VA_____       Date Requested_________

  1. Decedent/Registrant Information

 

Name _________________________________________ Date of Death ___/____/___

 

Place of Death ______________________

2. Requestor Information

Requested By:___________________________________

 

Mail To: ________________________________________

 

Mail Address_________________________  ______________ _____ __________

                        Number and Street                          City                       State    Zip Code

 

3. Authorized Individual Information – Complete this section if requesting authorized certified copy. Specify which category of authorized individual you are:

 

             A parent or legal guardian of the registrant.

 

             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.

 

             A child, grandparent, sibling, spouse, or domestic partner of the registrant.

 

             An attorney representing the registrant or the registrant’s estate; a person or agency empowered by statute or appointed by a court to act on behalf of the registrant or registrant’s estate.

 

             A funeral director ordering certified copies of a death certificate on behalf of an individual  specified in paragraphs (1) to (5), inclusive, of subdivision (a) of Section 17100 of the California Health and Safety Code.

 


 

 

 

4. Notarized Statement – A written request for an authorized certified copy must be accompanied by a notarized statement sworn under penalty of perjury that the requester is an authorized person, as required by state law. Your application will be returned if the required statement below is not signed and notarized. This section is not required for an informational only copy. 

 

Sworn Statement: I, ____________________, swear under penalty of perjury

                                    Printed Name

 

under the laws of the state of California, that I am an authorized person to obtain an authorized certified copy of this death record based on my relationship to the registrant, as specified in Section 3 of this application, in conformance with section 103526(c) of the California Health and Safety Code.

 

Sworn this _____day of ________, 200_, at _______________,  __________.

                  Day              Month                       City                          State

 

_________________________________

Signature

 

 

Certificate of AcknowledgementThis section is not required for funeral directors requesting copies on behalf of others.

 

State of ________________                      County of ________________________

 

On ____________< before me personally appeared  ____________________,

 

            __ personally known to me, or

            __ proved to me on the basis of satisfactory evidence,

 

to be the person whose name is subscribed to the above instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument.

                                                            WITNESS my hand and official seal.

                                                            (NOTARY SEAL)

 

____________________________

Notary Signature

 

Fees – Fees for certificate copies are established by state law. Include a check or money order payable to San Joaquin County Public Health Services. The current fee is $16.00 per copy.