San Joaquin County Public Health Services Mail Application for Certified Copy of Death Certificate |
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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 : |
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Certificate Type Requested: ___Authorized Certified ___Informational Only Number of Certificates _____ VA_____ Date
Requested_________ |
Name _________________________________________ Date of
Death ___/____/___ Place of Death ______________________ |
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2. Requestor Information Requested By:___________________________________ Mail To: ________________________________________ Mail Address_________________________ ______________ _____ __________ Number
and Street City State
Zip Code |
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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. |
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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 |
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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. (NOTARY
SEAL) ____________________________ Notary Signature |
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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.
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