Application For An Authenticated Apostilled Death Record {DCH-0569-DX-AUTH}

APPLICATION FOR AN AUTHENTICATED/APOSTILLED COPY--MICHIGAN DEATH RECORD Michigan Department of Health and Human Services INFORMATION ABOUT AUTHENTICATED CERTIFICATES: Authenticated (exemplified or containing an apostille) records are typically required by foreign governments for an adoption, work visas, marriage in a foreign country, or establishing residency. You must specify which country requires the document. Applying the apostille at the Secretary of State's Office of the Great Seal takes an additional 2-3 weeks after processing is complete at Vital Records. PART 1 - APPLICANT'S INFORMATION Applicant's Name: Mailing Address: Daytime Phone w/area code: PART 2 - CERTIFICATION OF INFORMATION PROVIDED By signing this application, I understand that I am agreeing to pay for a search of the State of Michigan Vital Records with the information that I provided. This does not guarantee that a record will be found. City: State: Other Phone w/area code: Zip: Applicant's Signature: PART 3 - PURPOSE FOR REQUESTING THE RECORD PART 4 - SPECIFY COUNTRY OF USE PART 5 - DEATH INFORMATION NEEDED TO FIND THE RECORD Date: If the exact date of death is unknown, please indicate the year you want searched. If you need additional years searched, please see Part 4 payment box for fee information. We can do a search without the "county" of death, but it will not be a thorough search. NAME OF DECEASED (at time of death) First Middle Last (mm/dd/yyyy) (mm/dd/yyyy) DATE OF BIRTH DATE OF DEATH DECEDENT'S GENDER PLACE OF Male DEATH Female Other variations of same name or locations City County State Please provide any of the following additional information that would help us locate the death record DECEDENT'S PLACE OF BIRTH State Country DECEDENT'S SOCIAL SECURITY NUMBER __ __ __ __ __ __ __ __ __ DECEDENT'S FATHER'S NAME DECEDENT'S MOTHER'S NAME First Middle Last First Middle Last PART 6 - FEES Includes one certified copy or no-find letter Base Fee: Includes One Year Search Additional Copies (Each) Additional Years Search , # yrs (when exact year unknown) Years you want searched: $42.00 x $26.00 x $12.00 $ $ $ For Accounting Use Only $ 42.00 $ Expedited "RUSH" Service (additional) $25.00 Payment to "State of Michigan" TOTAL Is your request complete? American LegalNet, Inc. www.FormsWorkFlow.com REQUESTING A MICHIGAN DEATH RECORD The Michigan Vital Records office has records of deaths that occurred in Michigan and were filed with the state since 1867. Occasionally, some of the records were not filed with the state; more records are missing from the pre-1906 files. Death records are not restricted documents in Michigan. Anyone can request that a search be conducted if the application is completed and signed, and submitted with the required fee paid. APPLYING IN PERSON LOCATION: South Grand Building, 1st Floor 333 S Grand Avenue Lansing MI 48933 (corner of Grand & Kalamazoo) LOBBY HOURS: 8:00 am - 5:00 pm M-F except for recognized state holidays. DIRECTIONS: Visit our website at: www.michigan.gov/vitalrecords or call 517-335-8666. SAME DAY SERVICE: Orders at our counter must be placed by 3:00 pm in order to receive same-day service. Additional "rush" fee of $12.00 is required for same-day service and you must allow up to a 2 hour waiting period for the order to be processed. Genealogy requests may take longer. PAYMENT: A money order, credit card or cash can be used at our front counter. A personal check can also be used if NOT same-day service. Make checks and money orders payable to "State of Michigan". www.michigan.gov/vitalrecords 517-335-8666 The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. PROCESSING TIMES FOR MAIL REQUESTS REGULAR SEARCH: The processing time for a regular request will be approximately 5 weeks, depending on the volume of requests received. EXPEDITED (RUSH) SEARCH: The processing time for a "rush" request will be approximately 2 weeks, depending on the volume of requests received. APOSTILLES: Applying the apostille at the Secretary of State's Office of the Great Seal for any request takes an additional 2-3 weeks after processing in Vital Records is completed. If you request just a certified copy from our office before 2:00 pm, you can go in person (five blocks) and have the apostille applied same-day. ADDITIONAL INFORMATION: If you find that the processing times listed do not meet your needs, please call our Eligibility Unit at 517-335-8666 and speak with a customer service representative. They may be able to offer additional help to meet your individual situation. MAIL APPLICATION TO REGULAR MAIL TO: Vital Records Requests PO Box 30721 Lansing MI 48909 RUSH MAIL TO: Vital Records RUSH PO Box 30721 Lansing MI 48909 DCH-0569-DX-AUTH (Rev. 12-16) By Authority of MCL 333.2882(1)(c), MCL 333.2883(2), and MCL 333.2891(1-4) MS PUBLISHER American LegalNet, Inc. www.FormsWorkFlow.com