Vital Records DivisionDeath Certificate Request* For District of Columbia Occurrences Only RESTRICTION: Family or legal representative only. Select here for details. Mail-In Form (Instructions) 1. Name of Deceased: 2. Social Security Number of Deceased: - - 3. Sex: Male Female 4. Date of Death: / / (mm/dd/yyyy) 5. Death Certificate No: (if known) 6a. Total number of copies of certificate requested: @ $18.00 each: 6b.(a) Number with cause of death included: (b) Number with cause of death omitted: 6c.Total Amount Enclosed: $ 7. Relationship to Deceased: Mother Father Spouse Other 8. Signature of Requester: ___________________________ 9. Date: ____/_____/________ Make Check/Money Order Payable to: DC Treasurer** Mail Certificate(s) to: 10. Name: 11. Address: 12.City/State/Zip Code 13. Day Phone: (required) *Copy of Requester's Photo ID is Required! Beginning January 1, 2009, all Mail-In requests must include a stamped self addressed return No. 10 (4 1/8" x 9 1/2 ") business size envelope. The DC Treasurer requires that all checks have an address imprinted on them to be accepted for deposit. Instructions to be completed:1. Print, sign, date form and a copy of requester's photo ID2. Enclose check / money order payable to: DC Treasurer3. Mail to: Government of the District of Columbia Department of HealthVital Records Division899 North Capitol Street, NE, First FloorWashington, DC 20002/ Phone: (202) 442-9303 Note: For security reason, please click this button to clear the data you have entered after printing this form. Death Application Instructions If record is not located a "Certificate of Search" will be issued and the payment for the search is non-refundable.The death transcript request form contains 13 questions. A separate copy of the request form should be completed for each person whose death record is being requested. However, multiple copies of a single death record may be requested on the same form. Items 1-4: Information about the deceased. Items 5: Information about the record being requested. Note: Persons entitled to purchase a vital record birth or death certificate included: The registrant An immediate nuclear family member A legal guardian A legal representative Item 6a: Please indicate the total number of certificates that you are requesting. Item 6b/a: Please indicate the number of requested copies of certificates on which you wish to have the cause of death included. Item 6b/b: Please indicate the number of requested copies of certificates on which you wish to have the cause of death omitted. Item 6c: Please indicate the total amount of money that you are enclosing. This amount should equal the requested number of transcripts multiplied by $18.If you send your request by mail, please enclose a check or money orderpayable to the DC Treasurer. The DC Treasurer requires that all checks must have an address imprinted on them to be accepted for deposit. The cost of either type of transcript is $18. Item 7: The requester's relationship to the deceased. Item 8: Please sign your signature once the mail-in form has been completed. Item 9: Please date the form. Item 10:-13 Information about the designated recipient of the certificate(s). After you print and sign your request, click the clear button to erase the data you have entered, mail the form and a copy of your picture ID with your payment to: Department of HealthVital Records Division899 North Capitol Street, NE, First FloorWashington, DC 20002(202) 442-9303 If record is not located a "Certificate of Search" will be issued and the payment for the search is non-refundable. RESTRICTION on Access to Death Certificates: Pursuant to D.C. Official Code Sec. 7-220, the Vital Records Division may issue a certified copy of a death certificate ONLY to an applicant having a direct and tangible interest in the requested death certificate.NOTE: This form should be used ONLY by a member of the registrant's immediate family, his/her guardian or legal representative.
Mail-In Form (Instructions) 1. Name of Deceased: 2. Social Security Number of Deceased: - - 3. Sex: Male Female 4. Date of Death: / / (mm/dd/yyyy) 5. Death Certificate No: (if known) 6a. Total number of copies of certificate requested: @ $18.00 each: 6b.(a) Number with cause of death included: (b) Number with cause of death omitted: 6c.Total Amount Enclosed: $ 7. Relationship to Deceased: Mother Father Spouse Other 8. Signature of Requester: ___________________________ 9. Date: ____/_____/________ Make Check/Money Order Payable to: DC Treasurer** Mail Certificate(s) to: 10. Name: 11. Address: 12.City/State/Zip Code 13. Day Phone: (required) *Copy of Requester's Photo ID is Required! Beginning January 1, 2009, all Mail-In requests must include a stamped self addressed return No. 10 (4 1/8" x 9 1/2 ") business size envelope. The DC Treasurer requires that all checks have an address imprinted on them to be accepted for deposit. Instructions to be completed:1. Print, sign, date form and a copy of requester's photo ID2. Enclose check / money order payable to: DC Treasurer3. Mail to: Government of the District of Columbia Department of HealthVital Records Division899 North Capitol Street, NE, First FloorWashington, DC 20002/ Phone: (202) 442-9303 Note: For security reason, please click this button to clear the data you have entered after printing this form. Death Application Instructions If record is not located a "Certificate of Search" will be issued and the payment for the search is non-refundable.The death transcript request form contains 13 questions. A separate copy of the request form should be completed for each person whose death record is being requested. However, multiple copies of a single death record may be requested on the same form. Items 1-4: Information about the deceased. Items 5: Information about the record being requested. Note: Persons entitled to purchase a vital record birth or death certificate included: The registrant An immediate nuclear family member A legal guardian A legal representative Item 6a: Please indicate the total number of certificates that you are requesting. Item 6b/a: Please indicate the number of requested copies of certificates on which you wish to have the cause of death included. Item 6b/b: Please indicate the number of requested copies of certificates on which you wish to have the cause of death omitted. Item 6c: Please indicate the total amount of money that you are enclosing. This amount should equal the requested number of transcripts multiplied by $18.If you send your request by mail, please enclose a check or money orderpayable to the DC Treasurer. The DC Treasurer requires that all checks must have an address imprinted on them to be accepted for deposit. The cost of either type of transcript is $18. Item 7: The requester's relationship to the deceased. Item 8: Please sign your signature once the mail-in form has been completed. Item 9: Please date the form. Item 10:-13 Information about the designated recipient of the certificate(s). After you print and sign your request, click the clear button to erase the data you have entered, mail the form and a copy of your picture ID with your payment to: Department of HealthVital Records Division899 North Capitol Street, NE, First FloorWashington, DC 20002(202) 442-9303 If record is not located a "Certificate of Search" will be issued and the payment for the search is non-refundable. RESTRICTION on Access to Death Certificates: Pursuant to D.C. Official Code Sec. 7-220, the Vital Records Division may issue a certified copy of a death certificate ONLY to an applicant having a direct and tangible interest in the requested death certificate.NOTE: This form should be used ONLY by a member of the registrant's immediate family, his/her guardian or legal representative.
