Bureau of Vital Records Request for Copy of Death Certificate

Please visit the Bureau of Vital Records website www.azhealth.gov for the following information:

• Fees• Locations, office hours, and availability of services• Eligibility requirements and acceptable identification• Correction, amendment, and registration information• Download forms

Telephone: 602-364-1300Apply Online: www.VITALCHEK.com (Refer to website for their current fees)

CUSTOMER ChECkliST 2 Clear photocopy of the front and back of your valid, signed

government photo ID OR have your signature notarized

2 Proof of relationship enclosed if required (birth certificates, certified court documents, marriage certificate, etc)

2 Sign the application

2 Include self-addressed stamped envelope

2 Correct fee enclosed

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Today's Date

Applicant's Full Name — Printed

First Middle last

APPliCANT'S SiGNATURE — REQUiRED

Date of Death

Place of Death — hospital or Residence

City County State

Name on Death Certificate

First Middle last

Mailing Address

Street City State Zip

# of Certified Copies Requested

Genealogy # of Noncertified Copies Requested

Purpose of Request Payment Method

Sex

2 Male 2 Female

Daytime Telephone Number Email Address

Your Relationship to Person on Certificate — Check One *PROOF of relationship MUST be provided. 2 Parent 2 Relative 2 Grandparent 2 Spouse 2 Gov't Agency 2 Other 2 Legal Interest (Beneficiary, Insurance Policy, Will, Personal Representative, Property, etc.)

Documentation must be provided to support this legal interest.

State of County of

On this day of , 20 before me personally appeared

(name of signer), whose identity was proven to me

on the basis of satisfactory evidence to be the person whose name is subscribed to this document, and who

acknowledges that he/she signed the above document.

Notary Signature My Commission Expires

Affix Seal/Stamp Here

Payment information

Card Number _______ - _______ - _______ - _______ Card Expiration Date / 2 Visa 2 MC

Signature of Cardholder — Must provide photocopy of valid government issued identification if cardholder is not the applicant. Amount to be Charged

$

For Office Use Only — State File Number / Serial Number

VS-158 (10/16)

Request iD

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2 Death 2 Fetal Death2 Stillbirth

Funeral home or Donation Facility

if Yes, list Claim (SSA, VA, ETC.)

Are Copies to be used for Government Claim?

2 Yes 2 No

Social Security Number Date of Birth

2 Hospital 2 Residence2 Other