APPLICATION FOR A FLORIDA DEATH RECORD
(For State Office Use Only)
Print Application
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Requirement for ordering : If applicant is self, parent, guardian, or legal representative, then the applicant must complete this application and provide valid photo identification. Acceptable forms of identification are the following: Driver's License , State Identification Card, Passport, and/or Military Identification Card .
FIRST MIDDLE LAST SEX
NAME OF DECEASED (Registrant) SOCIAL SECURITY NUMBER
(if known)
DATE OF DEATH - MONTH
DAY
YEAR (4 DIGIT)
IF YEAR NOT KNOWN, SPECIFY RANGE OF YEARS TO SEARCH
FLORIDA
NAME AND ADDRESS
OF
PLACE OF DEATH - CITY
COUNTY (REQUIRED)
DEATH FILE NUMBER (if known)
NAME
ADDRESS (CITY)
FUNERAL HOME
IMPORTANT
: Read the entire application before completing. Cause of death is confidential. conditions set forth in Florida Statutes.
To obtain and use a Florida death record under false or fraudulent purposes is a third-degree felony, punishable by the terms and
Quantity A fee of $5.00 entitles the applicant to one certification of the death record. Is this a fetal death? Do you need cause of death on this first certification?
Amount
Yes Yes
No No 1
$ 5.00
If a record is not found a certified "No Record Found" statement will be issued ADDITIONAL YEAR(s) SEARCH: a fee of $2.00 per year. Maximum search fee is $55.00 regardless of the total number of years to be searched.
Indicate Number of Years to be searched in 2nd box
$2.00
X
Quantity W/out Cause of Death
= $
Amount
W/ Cause Of Death Additional copies are $4.00 eachwhen ordered with this request.
$4.00
X Yes
+ No
= $ $
$
RUSH ORDERS (Optional) : $10.00 per order. Envelope must be marked "RUSH". For credit card requests refer to section "Options for Rush Service)
TOTAL AMOUNT ENCLOSED : Check or money order payable to Vital Statistics in U.S. Dollars (DO NOT SEND CASH) Florida Law imposes an additional service charge of $15 for dishonored checks MAIL APPLICATION TO:
Applicant's Name TYPE OR PRINT
State Office of Vital Statistics, Attn: Customer Services, P.O. Box 210, Jacksonville, FL 32231-0042
FIRST MIDDLE LAST SUFFIX
Funeral Director/Attorney as Applicant for Cause of Death Information
STATE RELATIONSHIP TO DECEDENT
LICENSE NUMBER
FUNERAL HOME OF RECORD
NAME OF PERSON REPRESENTED
Yes
SIGNATURE OF APPLICANT
No
HOME PHONE NUMBER
RESIDENCE STREET ADDRESS (AND APT.)
( (
)
WORK PHONE NUMBER
CITY STATE ZIP CODE
)
When cause of death information is requested, the applicant must state relationship to decedent and provide photo identification such as driver's license, state identification card, passport, or military identification.
[ ] Check this block if you wish to mail the certification(s) to a different address. Space is provided on the reverse side of this form for the name and address of the person to whom the death certificates are to be mailed if not the applicant.
DH Form 727 (Revised 11/04) Obsoletes Previous Forms
INFORMATION AND INSTRUCTIONS FOR DEATH RECORD APPLICATION
AVAILABILITY : Death registration was not required by state law until 1917, however there are some records on file dating back to 1877. ELIGIBILITY
: Any person of legal age (18) may be issued a certified copy of a death record without the cause of death.
WITHOUT CAUSE OF DEATH: Any person of legal age (18) may be issued a certified copy of a death record without the cause of death. CAUSE OF DEATH INFORMATION: Death records with the cause of death information may only be issued to the following individuals: the decedent's spouse or parent; to the decedent's child, grandchild or sibling, if of legal age; to any person who provides a will, insurance policy or other document that demonstrates his or her interest in the estate of the decedent, or to any person who provides documentation that he or she is acting on behalf of any of the above named persons. All requests for certification of a death certificate that includes the cause of death information, must include signature of the applicant, state his or her qualifying eligibility or a notarized Affidavit to Release Cause Of Death Information (DH Form 1959), which is available upon , request. If after reading the above information you are still uncertain regarding your eligibility for cause of death information, call our office (904) 359-6900 extension 9000 for assistance. The funeral director associated with the funeral home listed on the death record, or attorney representing an eligible person listed above must include their signature, professional license number, and the name and relationship of the person they are representing. If you are a funeral director not associated with the funeral home listed on the death record, or an attorney not representing someone . listed above as eligible to receive cause of death information, then a completed Affidavit to Release Cause of Death Information (DH Form 1959) must accompany this request. Cause of death information on death records over 50 years old is available to anyone completing an application and submitting the required fee. : If applicant is self, parent, guardian, or legal representative, then the applicant must complete REQUIREMENT FOR ORDERING this application and provide valid photo identification. If applicant is not one of the above, the Affidavit to Release A Birth Certificate must be completed by an authorized person and submitted in addition to this application form. Acceptable forms of identification are the following: Driver's License , State Identification Card, Passport, and/or Military Identification Card . NOTE : Florida clerks of court will not accept a death record with cause of death information stated when filing probate. NONREFUNDABLE : Vital record fees are nonrefundable, with one exception. Fees paid for additional copies when no record is found will be refunded upon written request. DATE OF DEATH : If date of death is unknown, the entire year specified will be searched. INFORMATION NEEDED : A search cannot be made without the decedent's name and year of death. If any of the other items requested on the front of this form are unavailable, some other identifying information (such as parents' names, birthplace, etc) may be helpful if multiple records are found for common names. APPLICANT'S SIGNATURE: Applicant's signature is required, as well as his/her name, valid residence address and telephone number
PROCESSING TIME
: Normal response time is 10 - 14 days. The processing time varies dependent upon the volume of work received and the resources available.
OPTIONS FOR RUSH SERVICE:
•
CREDIT CARDS: The state office is currently not permitted to accept credit cards, but there is a private firm that accepts such charges for a fee of $5.00 and transfers the order to Vital Statistics. Telephone (877) 550-7330 or (904) 359-6900 or fax (877) 550-7428. MAIL IN: Orders marked RUSH and with $10 rush fee included with the search fee, will be searched and certification or no record found statement made and ready to mail out within three workdays of receipt, provided that the record and the application are complete and in order. The three day time frame does not include the postal transit requirements, therefore add 4 to 5 postal transit days when figuring response time for this type of service. This does not include those records requiring an amendment action. WALK-IN SERVICE: Requests may be made at the state office in Jacksonville, located at 1217 Pearl Street. Orders prepaid before noon may be picked up after 3:30 p.m. Orders prepaid after noon may be picked up after 10:00 a.m. the next workday.
•
•
IF THE CERTIFICATION IS TO BE MAILED TO ANOTHER PERSON OR ADDRESS, USE THE SPACES BELOW TO SPECIFY SHIP TO NAME AND ADDRESS.
SHIP TO Name TYPE OR PRINT
HOME PHONE NUMBER
FIRST
MIDDLE
LAST
SUFFIX
SHIP TO STREET ADDRESS (AND APT.)
(
(
)
WORK PHONE NUMBER
CITY STATE ZIP CODE
) MAIL THIS APPLICATION WITH PAYMENT TO VITAL STATISTICS, P.O. BOX 210, Jacksonville, FL 32231-0042
http://www.myflorida.com/planning_eval/Vital_Statistics/index.html
DH Form 727 (Revised 11/04) Obsoletes Previous Forms