MAIL OR COUNTER APPLICATION FOR A CERTIFIED COPY AUTHENTICATED MICHIGAN DEATH RECORD www.michigan.gov/mdch ____________________________ STATE FILE NUMBER (If Known) INFORMATION ABOUT AUTHENTICATED CERTIFICATES Authenticated (exemplified or containing an Apostille) records are typically required by foreign governments for an adoption, work visas, marriage in a foreign country, or establishing residency. You must specify which country requires the document. The processing of an authenticated certificate takes approximately 3 to 4 weeks after receipt in the Vital Records office. Please allow additional time for mailing and our Department=s receipting of your payment. APPLICANT (PERSON REQUESTING RECORD) PLEASE PRINT CLEARLY AND LEGIBLY DATE: Applicant=s Name: = Address: City/State/Zip: K APPLICANT==S SIGNATURE: K (Sign Here) ___________________________________________________________ Must be signed in order to process Daytime Phone: ( K ) Home Phone: ( ) Please specify which FOREIGN COUNTRY requires the document (Cannot be U.S.) REQUESTED DEATH INFORMATION IF THE EXACT DATE OF DEATH IS UNKNOWN: Please indicate the year you want searched. If the record is not found in that year=s files, we will search the files for the year before and = the year after. If you want additional years searched, please see the payment box for additional information. NAME OF DECEASED: (Name at time of death) First Male GENDER Female Middle PLACE OF DEATH: DATE OF DEATH _____________________ Month Day Year Last City County State PLEASE PROVIDE ANY OF THE FOLLOWING INFORMATION (IF KNOWN) THAT WOULD HELP US LOCATE THE DEATH RECORD: Decedent=s = Date of Birth: ____________________ Mo Day Year OR Decedent=s = Age at Death: ____________ Decedent=s = Place of Birth: State Decedent=s = Mother=s Name: = First Middle Last Decedent=s = Father=s Name: = First Middle Country Last REQUESTING AN AUTHENTICATED MICHIGAN DEATH RECORD The Michigan Vital Records office has records of deaths that occurred in Michigan and were filed with the state since 1867. Some of the records were not filed with the state; more records are missing from the pre-1906 files. Anyone is eligible to request a copy of a Michigan death record if the application is completed and signed and the required fee is paid. PAYMENT - NO ORDER WILL BE PROCESSED WITHOUT PROPER FEE SUBMITTED WITH A SIGNED APPLICATION SEARCH FEES ARE NON-REFUNDABLE: Fees are established by state statute. A search fee covers the cost of the basic 3-year search and includes either one authenticated copy of the record or an official statement that the record is not filed with the state. A basic search includes the files for the year specified as the death year, as well as the year before and the year after. REFUNDABLE FEES: Payment for additional copies will be refunded if the search indicated that the record is not filed with the state. A refund check would be mailed to you by the Department of Treasury, usually within 3-4 weeks. RUSH SERVICE: Applies to processing time in Vital Records and not the Great Seal. WE CANNOT PROCESS YOUR ORDER WITHOUT PAYMENT. IF MAILING, PLEASE REMEMBER TO INCLUDE CHECK OR MONEY ORDER. PAYMENT MUST BE MADE IN U.S. FUNDS BY CHECK OR MONEY ORDER PAYABLE TO THE A STATE OF MICHIGAN@ @ Search (non-refundable) Includes One Authenticated Copy $ 29.00 $ _______ Additional Authenticated Copies ($15.00 for each additional authenticated copy) $ 15.00 Each $ EXPEDITED A RUSH@ SERVICE @ $ 10.00 $ No. Years $ (Additional) Additional Search When Exact Date is Unknown: $29.00 fee includes a 3-year search Each additional year is $12.00 per year __________ Specify Which Additional Years to be Searched: ______________________________ TOTAL ENCLOSED: Mail application with payment to: VITAL RECORDS REQUESTS PO Box 30721 Lansing MI 48909 $ 12.00 each $ QUESTIONS: (517) 335-8666 DCH-0569-DXAUTH Rev 3/9/06 By Authority of MCL 333.2882(1)(c) , MCL 333.2883(2) and MCL 333.2891(1-4) American LegalNet, Inc. www.FormsWorkflow.com