To complete the Death Order Form: Fill out the second and third

To complete the Death Order Form:
Fill out the second and third page1. Fax Cover sheet
2. Written Application for Unrestricted Certified Copy of a
Death Record
The application is in PDF format, for convenience you can easily
fill it out online.
Simply click into the fields of the application with your mouse.
Click on the applicable check boxes.
Once you have entered your information print the application.
If paying by Credit Card complete the online order form.
Follow these steps to complete the process1. Take the application to a notary and have the application
notarized.
2. Fax the completed and notarized application to our office
within 10 calendar days:
Fax# 925-335-7888
or
925-335-7887
Please, do not fax the entire packet only the Fax Cover Sheet
and the Written Application for Unrestricted Certified Copy
of a Death Record is required.
Internet Death Certificate Order
Fax Cover Sheet
To: Contra Costa County Clerk Recorder
Fax:
OfficePhone: 925-335-7900
Comments:
From:
Date:
Pages:
WRITTEN APPLICATION FOR UNRESTRICTED CERTIFIED COPY
OF A DEATH RECORD ($15.00 general public or $12.00 government agencies only).
PLEASE REVIEW THE INSTRUCTIONS ON THE BACK BEFORE COMPLETING
1
Death Certificate Information Name:
First
Date of Death:
Month
Father’s Name:
Day
Name:
Middle
First
First
Mailing Address:
If different from above
Last
Middle
Last
Middle
Last
Number and Street
City
State
Zip Code
Number and Street
City
State
Zip Code
Telephone Number: (with area code) (
4
Last
Applicant Information
Address
3
Middle
City of Death:
First
Mother’s Maiden Name:
2
Year
Number of copies requested
)
To obtain an Unrestricted Certified Copy you must be authorized under section 103526 of the Health and
Safety Code. Please review the reverse side of this application to determine which section applies and
check the appropriate box below.
o 103526(c)(1)
o 103526(c)(2)
o 103526(c)(5)
o 103526(c)(6)
o 103526(c)(3)
o 103526(c)(4)
I (printed name)
swear under penalty of perjury that I am an authorized person,
as defined in California Health and Safety Code Section 103526(c), and am eligible to receive a certified copy of the
death record identified on this application form. Sworn this
day of ,
,
Signature:
at
(City)
5
Certificate of Acknowledgment
State of
County of
Notary public
On
before me, , personally appeared
,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature
Office use only: Reel/Image
Certificate #
Paper#
(seal)
Deputy
Death written unrestricted app 12/07
INSTRUCTIONS TO COMPLETE WRITTEN APPLICATION FOR
UNRESTRICTED CERTIFIED COPY OF A DEATH RECORD
1
Death Certificate Information:
Print or type number of copies requested
Print or type name of registrant
Print or type date of death
Print or type city of death
Print or type father’s name
Print or type mother’s maiden name
2
Applicant Information:
Print or type name of person ordering copy
Print or type address of person ordering copy
Print or type mailing address of person ordering copy, if different than address above
Print or type telephone number of person ordering copy, including area code
3
Using the list below, check the box next to the code section in item 3 on the front of this application that
authorizes you to obtain an unrestricted certified copy of a death record:
103526 (c)(1) The registrant or a parent or legal guardian of the registrant
103526 (c)(2) A party entitled to receive the record as a result of a court order, or an attorney or a licensed
adoption agency seeking the death record in order to comply with the requirements of Section 3140 or
7603 of the Family Code.
103526 (c)(3) A member of a law enforcement agency or a representative of another governmental agency,
as provided by law, who is conducting official business.
103526 (c)(4) A child, grandparent, grandchild, sibling, spouse or domestic partner of the registrant.
103526 (c)(5) An attorney representing the registrant or the registrant’s estate, or any person or agency
empowered by statute or appointed by a court to act on behalf of the registrant or the registrant’s estate.
103526 (c)(6) Any funeral director who orders certified copies of a death certificate on behalf of any
individual specified in paragraphs (1) to (5), inclusive, of subdivision (a) or Section 7100 of the Health
and Safety Code
4
DO NOT COMPLETE THIS PART UNTIL YOU ARE WITH THE NOTARY PUBLIC WHO WILL
PREPARE THE CERTIFICATE OF ACKNOWLEDGMENT IN ITEM 5.
Section 103526 of the California Health and Safety Code requires anyone requesting an unrestricted
certified copy of a death record to complete and sign a sworn statement under penalty of perjury.
5
Certificate of Acknowledgment
Complete items 1 to 3 on the front of this application then bring to a notary public. Complete and sign the
sworn statement in item 4 in front of the notary public. Request the notary acknowledge your signature in
the sworn statement in item 4. Mail the original application with the appropriate fee ($15.00 general public
or $12.00 government agencies only).
To: Contra Costa County Recorder
P.O. Box 350
Martinez, CA 94553
Death written unrestricted app 12/07