Death Certificate Application Form

Information of the decedent

Complete the following information regarding the details of the deceased person on record.

Decedent's State of Death *

Decedent's State of Birth

Decedent's City/Town of Death *

Decedent's County of Death

Decedent's Date of Birth

Month of Death *

Day of Death *

Year of Death *

Decedent's Date of Birth

Month of Birth *

Day of Birth *

Year of Birth *

Decedent's Social Security number if known

Decedent's Personal Information

Please enter the full name of the person on record at time of death as shown on the Death Certificate.

Decedent's First Name *

Decedent's Middle Name *

Decedent's Last Name *

Decedent’s Sex *

Male

Female

Full Name of Decedent's Mother / Parent

First Name *

Middle Name *

Last Name *

Full Name of Decedent's Father / Parent

First Name *

Middle Name *

Last Name *

Contact Information

Please enter your full name as shown on your ID and your contact information.

First Name *

Middle Name *

Last Name *

Phone Number *

Email *

Delivery Information

Please enter the physical address where you want the certificate to be delivered.

Address 1 (Street number and street name) *

Address 2 (if applicable: Apt, suite, floor) *

City *

State *

Zip Code *

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Process to obtain a certificate

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Disclaimer: VitalCert is an independent online platform not affiliated with any governmental agency. We assist customers in preparing their birth certificate applications quickly and conveniently. Our services expedite form completion, reducing the need for multiple visits to state Health Departments. Please be aware that while our services require a fee, blank forms can be obtained at no cost from official state sources. By utilizing our services, you acknowledge and accept the above terms.