V03 ( I am: A party entitled to receive the record as a result of a court orderA member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting official business. by a 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 FOR OFFICIAL USE ONLY COUNTY OF SAN DIEGO www.sdarcc.com APPLICATION FOR A OR $2.00 226 PER COPY FEES ARE NON-REFUNDABLE FOR OFFICIAL USE ONL Type of identification provided: [ ] Driver222s License [ ] Military ID [ ] Passport[ ] Other I would like a Certified Copy of the record identified on theapplication form. (In order to receive a Certified Copy, youmust indicate your relationship to the person named on theapplication form by selecting from the list below.) I would like a Certified Informational Copy of the recordidentified on the application form. (You are not requiredto select from the list below or complete the Statementof Identity in order to receive an Informational Copy.) STATEMENT OF IDENTITY FOR AUTHORIZED PERSON I, , swear under penalty of perjury that I am an authorized person, as (Print Name) American LegalNet, Inc. www.FormsWorkFlow.com I, , declare under penalty of perjury under the laws of the State of California, 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 record of the following individual(s): Subscribed to this day of , 20, at , . (Day) (Month) (Yr) (City) (State) (Applicant222s Signature) Note: If submitting your order by mail and requesting a Certified Copy, you must have your sworn statement notarized using the Certificate of Acknowledgment 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 ACKNOWLEDGMENT State of County of On before me, , (nsert name 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. NOTARY SIGNATURE Name Address City, State, Zip Email Phone () Number of copies X $2.00 = Please mail this request along with your payment (check or money order payable to San Diego County Recorder) to: A notary public or other officer completing this certificate verifies only t he identity of the individual who signed the document to whichthis certificate is attached, and not to the truthfulness, accuracy, or validity o f that document Name of Person Listed on Certificate Number of Copies Applicant222s Relationship to Person Listed on Certificate WITNESS my hand and official sea American LegalNet, Inc. www.FormsWorkFlow.com