RIVERSIDE COUNTY ASSESSOR-COUNTY CLERK-RECORDER APPLICATION FOR CERTIFIED COPY OR SEARCH OF A DEATH RECORD PLEASE REVIEW THE INSTRUCTIONS ON THE BACK BEFORE COMPLETING 1 DEATH RECORD or CERTIFICATE OF NO RECORD INFORMATION FEE $14.00 Name of Deceased_____________________________________________________________________________________ First Middle Last Date of Death _______________________________ City of Death ________________________________ 2 3 Date of Birth ___________________________________ Number of Copies ___________________________  I am requesting an AUTHORIZED copy  I am requesting an INFORMATIONAL copy If you are requesting an Informational copy, please skip to section 4. To obtain an Authorized Certified Copy you must check the appropriate box below: I am:    The parent or legal guardian of the person listed on the death record.   A person who has a court order to obtain the record.  Any agent or employee of a funeral establishment who acts within the course and scope of his or her employment and who orders certified copies of a death certificate on behalf of any individual specified in paragraphs (1) to (5), inclusive, of s ubdivision (a) of Section 7100. A child, grandparent, grandchild, sibling, spouse or domestic partner of the person listed on the death record. A member or representative of a government agency, as provided by law, who is conducting official business. (Companies representing a government agency must provide authorization from the government agency.) An attorney representing the person or the person’s estate whose name is listed on the death record or any person or agency appointed by court to act on behalf of the person or the person’s estate whose name is listed on the death record. (If you are requesting a Certified Copy under a power of attorney, please include a copy of the power of attorney with this application form.) Requested by: ________________________________________ Mail/Issue To: ________________________________________ Name Name of Person Receiving Copies, If Different from Applicant ________________________________________ ________________________________________ Street Address 4 Mailing Address for Copies, if Different from Applicant ________________________________________ ________________________________________ City City State Zip Phone # (________)_________________________ 5 I.D. # State Zip _____________________________________ I, _________________________________ swear or affirm under penalty of perjury that I am an authorized person, (Print Full Name) as defined in California Health and Safety Code Section 103526 (c), eligible to receive a certified copy of the death record identified on this application form. Sworn: ____________________________________ at ____________________________ _______ Date (mm/dd/ccyy) City State Signature: _____________________________________________________________________ (Applicant Signature) (If ordering in person you must sign in front of the Clerk) BELOW SECTION FOR OFFICE USE ONLY Receipt # Cash  Check # Check Debit / Credit   Amount Paid  Counter  Mail  Gov’t Agency  Govt. Stamped Credit Card # / Exp. Date   Total $ Due Year / Certificate # Long Amount Type of I.D., Identifying Numbers and Exp. Date Refund Amount Clerks Initials Do Not Charge Fee, Contact State Charge Search Fee, Contact ACR 406 (Rev. 08/2012) State or ________________ Searched years from ___________ to ____________ by: ____________ Available in Alternate Formats American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS TO COMPLETE APPLICATION FOR A CERTIFIED COPY OR SEARCH OF A DEATH RECORD If no record of the death is found, pursuant to Health and Safety Code 103650, the $14.00 fee will be retained for searching and a Certificate of No Record will be issued. PLEASE PRINT IN BLACK OR BLUE INK 1 Death Certificate Information: Give all the information you have available for the identification of the record. Riverside County only has records of deaths that occurred in Riverside County. For all other death records you must contact the county in which the death occurred or contact the Department of Health Services, Office of Vital Records-M.S. 5103, P.O. Box 997410, Sacramento, CA 95899-7410. Phone number: (916) 445-2684. 2 Section 103526 of the California Health and Safety Code restricts who is allowed to obtain an authorized certified copy of a death record. You must be one of the authorized persons described in the six sentences in section 3 on the front of this application. Those who are not authorized will receive an INFORMATIONAL CERTIFIED COPY with the words “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY” imprinted across the face of the copy. An AUTHORIZED CERTIFIED COPY of a death record may be required to obtain death benefits, claim insurance proceeds, notify social security and obtain other services related to an individual’s identity. If you are requesting an informational copy you do not need to complete the sworn statement at the bottom of this application. 3 If you are requesting an authorized certified copy of a death record, please check the box that allows you to obtain the authorized certified copy. 4 Print or type name of person ordering copy. Print or type address of person ordering copy. 5 A governmental issued picture I.D. is required if ordering in-person. Please have it ready. Section 103526 of the California Health and Safety Code requires anyone requesting an authorized certified copy of a death record to complete and sign the sworn statement on the front of this application. Please print your name in the space provided and complete the space for the date and location for when and where you sign this statement. BY MAIL: When submitting multiple certificate requests at the same time, all requests must contain the completed sworn statement on the front of this application but only one request would require the notary statement. Any member of a law enforcement agency or a representative of a state or local government agency, as provided by law, who applies for a birth certificate conducting official business, is NOT required to provide the notarized statement below. (a) For an AUTHORIZED copy, complete the sworn statement in front of a notary public. (b) For an INFORMATIONAL copy, the sworn statement in section 5 on the front of this application and the notarized statement below are NOT required. Send the application and a check payable to Riverside County Recorder, P.O. Box 751, Riverside, CA 92502-0751 Certificate of Acknowledgment State of _____________________ County of __________________________ On ______________ before me, _____________________________________________________, personally appeared (Date) (Insert name and title of the officer) _______________________________________________________________________________________________ , (Insert name of person being acknowledged) 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. Signature _____________________________________________ (Officer signature) ACR 406 (Rev. 08/2012) (seal) Available in Alternate Formats American LegalNet, Inc. www.FormsWorkFlow.com