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 PLEASE PRINT IN BLACK OR BLUE INK 1 DEATH RECORD or CERTIFICATE OF NO RECORD INFORMATION FEE $12.00 Name of Deceased__________________________________________________________________________ First Middle Last Date of Death ________________________ City of Death _________________________ 2 3 4 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 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.) A person who has a court order to obtain the record. 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.) 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 subdivision (a) of Section 7100. Purchased by: For Office Use Only: Yr./Ctf #___________ __________________________________________ Rect. #____________Cash_______Check_______ Name __________________________________________ Total $____________Govt. Agency___________ Street Address Ck #__________Amt $_______Long $_________ __________________________________________ D/L #____________________EXP.___________ City State Zip (_____)____________________________________ Clerk____________________________________ Telephone STOP! If ordering an AUTHORIZED Certified Copy in-person, YOU MUST complete the section below in the presence of a clerk and present a government issued picture I.D. This section must also be completed for orders by mail. 5 I, _______________________________ swear or affirm under penalty of perjury that I am an authorized person, as Printed Name 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 this _____ day of ________________, 20_____ , at ____________________________________________ (City, State) Signature: __________________________________________________ ACR 406P-AS4CEO (Rev. 12/2007) Available in Alternate Formats American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS TO COMPLETE APPLICATION FOR A CERTIFIED COPY OF A DEATH RECORD If no record of the death is found, pursuant to Health and Safety Code 103650, the $12.00 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) 445-1719. 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: For an AUTHORIZED copy, complete the sworn statement in section 5 on the front of this application and sign below in front of a notary public. 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. Funeral directors who are ordering death certificates on behalf of an authorized individual, 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 death certificate conducting official business is NOT required to provide the notarized statement below. For an INFORMATIONAL copy, the sworn statement in section 5 on the front of this application and the notarized statement below are NOT required. ________________________________________ _____________________________________________ Print Name Certificate of Acknowledgement Applicant’s signature State of ____________________ County of ____________________________ On ______________ before me, _____________________________________________________________, personally appeared (here insert name and title of the officer) ________________________________________________________________________________________________________, 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 (seal) Send original application and appropriate fees with check payable to: Riverside County Recorder, P.O. Box 751, Riverside, CA 92502-0751 ACR 406P-AS4CEO (Rev.12/2007) Available in Alternate Formats American LegalNet, Inc. www.FormsWorkflow.com