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 :
Certificate Type Requested: ___Authorized Certified ___Informational Only
Number of Certificates _____ VA_____ Date Requested_________
Name _________________________________________ Date of Death ___/____/___
Place of Death ______________________
2. Requestor Information
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
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
Certificate of Acknowledgement – This 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.
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.