COUNTY OF SAN DIEGO ASSESSOR/RECORDER/COUNTY CLERK ERNEST J. DRONENBURG, JR. APPLICATION FOR DEATH CERTIFICATE BY MAIL $12.00 FEE FOR DEATH CERTIFICATE OR LETTER OF NO RECORD NON-REFUNDABLE Effective July 1, 2003, California State Law, Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive certified copies of death records. Those who are not authorized by law to receive a certified copy will receive a certified copy marked “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” Please indicate below whether you would like a Certified Copy or a certified Informational Copy. Please wait 3 weeks from the date of event before submitting your request.  I would like a Certified Copy of the record identified on the application form. (In order to receive a Certified Copy, you must indicate your relationship to the person named on the application form by selecting from the list below.) I am:        I would like a certified Informational Copy of the record identified on the application form. (You are not required to select from the list below or complete the statement of identity in order to receive an Informational Copy.) The parent or legal guardian of the registrant (person named on certificate). A party entitled to receive the record as a result of a court order. A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting official business. A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant. An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a court to act on behalf of the registrant or the registrant’s estate. Any funeral director 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. DEATH INFORMATION (PLEASE PRINT OR TYPE) - $12.00 for each certified copy Name of Decedent – First Name Middle Name Last Name Date of Death County of Death No. of Copies DEATH INFORMATION (PLEASE PRINT OR TYPE) - $12.00 for each certified copy Name of Decedent – First Name Middle Name Last Name Date of Death County of Death No. of Copies DEATH INFORMATION (PLEASE PRINT OR TYPE) - $12.00 for each certified copy Name of Decedent – First Name Middle Name Last Name Date of Death County of Death No. of Copies DEATH INFORMATION (PLEASE PRINT OR TYPE) - $12.00 for each certified copy Name of Decedent – First Name Middle Name Last Name Date of Death County of Death No. of Copies Note: The Statement of Identity must accompany this request in our office before a certificate can be issued. Requestor’s Name: ___________________________________________________________________________________________ PLEASE PRINT Vitals Form #V3A (12/28/2010) American LegalNet, Inc. www.FormsWorkFlow.com 1 of 2 STATEMENT OF IDENTITY I, _____________________________________________, swear under penalty of perjury under the laws of the State of (Print Name) 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 birth or death record of the following individual(s): Name of Person Listed on Certificate Type No. of Copies Birth Death Birth Death Birth Death Birth Relationship to Person Listed on Certificate Death Sworn this _______ day of ____________, 20______, at_________________________________, _______________. (Day) (Month) (City) (State) _______________________________________________________ (Signature) Note: If submitting your order by mail and requesting a Certified Copy (not an Informational Copy), you must have your sworn statement notarized using the Certificate of Acknowledgement 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 requester may have a different authorized relationship to each record being requested, (i.e. Mother on one request, Registrant on another request, etc.). CERTIFICATE OF ACKNOWLEDGEMENT State of _____________________________________County of _____________________________________________________ On __________________________, before me, __________________________________________________________________, (Insert name and title of the 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. WITNESS my hand and official seal. ______________________________________________________ NOTARY SIGNATURE Mail Certificate to: Name _______________________________________________ Address _____________________________________________ City, State, Zip _______________________________________ Email _______________________________________________ Phone (______) _______________________________________ Please mail this request along with your payment (check or money order payable to SD County Recorder) to: San Diego Recorder/County Clerk Attn: Vital Records P.O. Box 121750 San Diego, Ca 92112-1750 Number of Birth _____________ x $19.00 = ________________ Number of Death ____________ x $12.00 = ________________ TOTAL = ________________ Vitals Form #V3B/4B (12/28/2010) American LegalNet, Inc. www.FormsWorkFlow.com 2 of 2