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Application For Death Certificate (By Mail) V4ABD - California

Application For Death Certificate (By Mail) Form. This is a California form and can be used in Assessor-Recorder-County Clerk San Diego Local County .
 Fillable pdf Last Modified 8/4/2014
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COUNTY OF SAN DIEGO ERNEST J. DRONENBURG, JR. ASSESSOR/RECORDER/COUNTY CLERK www.sdarcc.com BY MAIL APPLICATION FOR A DEATH CERTIFICATE, OR LETTER OF NO RECORD FOR OFFICIAL USE ONLY $21.00 ­ PER COPY FEES NON-REFUNDABLE Per California State Law, Health and Safety Code, Section 103526(c), permits only FOR OFFICIAL USE ONLY authorized persons as defined below to request certified copies of Death Records. Type of identification provided, if processed in person: Those who are not authorized by Law to receive a certified copy will receive a [ ] Driver's License [ ] Military ID certified informational copy marked "INFORMATIONAL, NOT A VALID DOCUMENT [ ] Passport [ ] Other ___________ TO ESTABLISH IDENTITY." If we cannot identify the record based on the information you provided, State Law requires that we retain the fee and issue a "Letter of No Record". Please wait 6 weeks from the date of the event before submitting your request. You will be asked to present a valid photo ID for all in-person requests. I would like a Certified Copy of the record identified on the application I would like a Certified Informational Copy of the record identified form. (In order to receive a Certified Copy, you must indicate your on the application form. (You are not required to select from the relationship to the person named on the application form by selecting list below or complete the statement of identity in order to receive from the list below.) an Informational Copy.) I am: The parent or legal guardian of the decedent (person named on certificate). A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption agency seeking the birth record in order to comply with the requirement of Section 3140 or 7603 of the Family Code. 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, grandchild, sibling, spouse, or domestic partner of the registrant. 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. 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) of Section 7100. DEATH INFORMATION ON CERTIFICATE (PLEASE PRINT OR TYPE) - $21.00 for each certified copy First Name Middle Name Last Name Date of Death County of Death No. of Copies DEATH INFORMATION ON CERTIFICATE (PLEASE PRINT OR TYPE) - $21.00 for each certified copy First Name Middle Name Last Name Date of Death County of Death No. of Copies DEATH INFORMATION ON CERTIFICATE (PLEASE PRINT OR TYPE) - $21.00 for each certified copy First Name Middle Name Last Name Date of Death County of Death No. of Copies Note: The Statement of Identity must accompany this request in our office before a certificate can be issued. Requestor's Name _______________________________________________________________________ PLEASE PRINT V4ADE (1/17/14) American LegalNet, Inc. www.FormsWorkFlow.com 1 OF 2 SWORN STATEMENT I, _________________________________, declare under penalty of perjury under the laws of the State of California, that I am an authorized (Print Name) person, as defined in California Health and Safety Code, Section 103526(c), and am eligible to receive a certified copy of the death record of the following individual(s): Number of Applicant's Relationship to Person Listed on Certificate Name of Person Listed on Certificate Copies Subscribed to this _______ day of ______________, 20___, at _________________________, ________________. (Day) (Month) (Yr) (City) (State) ______________________________________________________ (Applicant's signature) Note: If submitting your order by mail and requesting a Certified Copy, you must have your sworn statement notarized using the Certificate of Acknowledgement below. The notary is only verifying the identity of the person requesting the copy not the relationship to the registrant. Only one notarization is required even though the requestor may have a different authorized relationship to each being requested, (i.e. Mother on one request, Registrant on another request, etc.). CERTIFICATE OF ACKNOWLEDGEMENT State of _______________________________ County of ____________________________________________________________ On _______________________________ before me, _______________________________________________________________, (Insert name and title of the officer) 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 Personally Known OR Produced Identification. Type of Identification produced _________________________ ________________________________________________ NOTARY SIGNATURE Mail Certificate to: Name __________________________________________________ Address ________________________________________________ City, State, Zip ___________________________________________ Email __________________________________________________ Phone (______) _________________________________________ Number of copies ____________X $21.00 = ___________________ V4ADE (1/17/14) American LegalNet, Inc. www.FormsWorkFlow.com Please mail this request along with your payment (check or money order payable to SD Recorder/County Clerk) to: San Diego Recorder/County Clerk Attn: Vital Records P.O. Box 121750 San Diego, CA 92112-1750 2 OF 2
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