MAIL OR COUNTER APPLICATION FOR A CERTIFIED COPY www.michigan.gov/mdch ___________________ MICHIGAN DEATH RECORD APPLICANT STATE FILE NUMBER (PERSON REQUESTING RECORD) PLEASE PRINT CLEARLY AND LEGIBLY DATE: / (If Known) / Applicant=s Name: Address: K City/State/Zip: K APPLICANT=S SIGNATURE: = (Sign Here) ____________________________________________________________ Must be signed in order to process Daytime Phone: ( REQUESTED DEATH INFORMATION ) _________________________________ Home Phone: ) ________________________________ DATE OF DEATH 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 GENDER 9 Female PLACE OF DEATH: 9 Male ( Middle City _____________________ Month Day Year Last 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: Decedent=s Social = Security Number State Country __ __ __ Decedent=s = Mother=s Name: = First Middle First Middle __ __ __ __ Last Decedent=s = Father=s Name: = __ __ Last REQUESTING A 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. PURPOSE FOR REQUESTING RECORD PAYMENT MUST BE MADE IN U.S. FUNDS BY CHECK OR MONEY ORDER PAYABLE TO THE ASTATE OF MICHIGAN@ @ Fees are established by state statute. A search fee covers the cost of the basic search and includes either one copy of the record or an official statement that the record could not be located in the state files. Payment for additional copies will be refunded if the record cannot be located. A refund check would be mailed to you by the Department of Treasury, usually within 3-4 weeks. TURN-AROUND TIME - For regular or expedited mail requests, please allow additional time for mailing and our department=s receipting of your payment. * EXPEDITED SEARCH - All search information is required in order to request expedited service. If you pay the expedited search fee (in addition to the regular search fee), a counter request will be processed in 1-3 hours if death year is 1916 to the present. For a mail request, if death year is 1916 to the present, your request will be processed within 2 weeks of receipt in the vital records office. For a counter or mail request, if death year is prior to 1916, the processing time will be 3 weeks. * EXPEDITED SERVICE - Applies to standard three-year searches. Not available for extra year searches. REGULAR SEARCH - If the death year is 1916 to the present, your request will be processed within 4 weeks of receipt in the vital records office. If the death year is prior to 1916, the processing time will be 1-3 months. DCH-0569-DX Rev 3/9/06 By Authority of MCL 333.2882(1)(c), MCL 333.2883(2) and MCL 333.2891(14) $ 26.00 $ ______ Additional Copies (Each) $ 12.00 $ * EXPEDITED SEARCH (Non-Refundable) (In addition to the regular search fee) __________________________________________________________ __________________________________________________________ Search (Non-Refundable) Includes One Certified Copy $ 10.00 Additional $ * Additional Search When Exact Date is Unknown: $26.00 fee includes a 3-year statewide search Each additional year is $12.00 per year No. Years Specify Which Additional Years to be Searched: ___________________________________ $12.00 each TOTAL ENCLOSED: __________ $ $ WE CANNOT PROCESS YOUR ORDER WITHOUT PAYMENT. IF MAILING, PLEASE REMEMBER TO INCLUDE CHECK OR MONEY ORDER. IF REGULAR SEARCH MAIL TO: VITAL RECORDS REQUESTS PO Box 30721 Lansing MI 48909 QUESTIONS: IF EXPEDITED SEARCH MAIL TO: VITAL RECORDS RUSH PO Box 30721 Lansing MI 48909 (517) 335-8666 American LegalNet, Inc. www.FormsWorkflow.com