REQUEST FOR VERIFICATION OF A MICHIGAN DEATH RECORD Michigan Department of Health and Human Services For Additional Information: 517-335-8666 www.michigan.gov/vitalrecords Please type or print clearly and legibly APPLICANT (PERSON REQUESTING VERIFICATION) DATE: / / Agency Name Area Code and Phone Number ( ) Mailing Address City/State/Zip APPLICANT S SIGNATURE (Sign Here) Must be signed in order to process . By signing this application, I understand that I am agreeing to pay for a search of the State of Michigan vital records. This does not guarantee that a record will be found. VERIFICATION INFORMATION - A request for a verification of a Michigan dea th record will be returned to you stamped with an indication that a record was identified which matched the supplied facts , or that no record could be identified which matched the supplied facts. State law (MCL 333.2881(2)) allows for verification of ONLY name of the subject o f the dea th record , date of dea th, place of dea th and filing date (date the record was originally fi led or received by the local registrar not date of issuance) . This information must match exactly what is on the record. No copy of the record or additional information can be verified or supplied by the Vit al Records O ffice. State law requires a n $18 .00 fee for each search of the facts for verification. FACTS TO BE VERIFIED Must match exactly what is on the record Decedent First Middle Last Date of Dea th Month Day Year County of Death Date of Filing - Enter ONLY i f you have a copy of the record. (Date the record was originally filed or received by the local registrar and not the date of issuance) M onth Day Year TURN - AROUND TIME REGULAR SEARCH - Proc essing time for mail - in requests will be approximately 3 weeks , depending on volume of requests received . EXPEDITED SEARCH Processing time for a mail - in request will be approximately 2 weeks , depending on volume of requests received. A counter request will be processed in 1 - 2 hours . 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. DCH-0569-VERDX Rev 5-2017 By Authority of MCL 333.2881(2) and 333.2891(4)(f) VERIFICATION STAMP ( Vital Records Official Stamp) PAYMENT For mail - in requests, payment can be made in U.S. funds by check or money order payable to the be used for counter requests. No checks if same - day service is requested. Each Verification Search (Non - Refundable) $ 18 .00 * EXPEDITED SEARCH Add $12.00 (In addition to the regular search fee) $ TOTAL: $ We cannot process your request without payment. When mailing, please remember to include check or money order. IF REGULAR SEARCH: IF EXPEDITED SEARCH: VITAL RECORDS REQUESTS VITAL RECORDS RUSH P.O. Box 30721 P.O. Box 30721 Lansing MI 48909 Lansing MI 48909 If you wish to have the results of the verification faxed to you, please indicate the fax number here: ( ) American LegalNet, Inc. www.FormsWorkFlow.com