Pueblo Divorce Records by nwl14056

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									                                            Vital Records Section
                                                                                                                       File Number
                                               101 W. 9th Street
                                              Pueblo, CO 81003
                                            719-583-4300 (press 4)                                  ABN Certificate Number Issued
                                          www.co.pueblo.co.us/pcchd
                                                                                                                    Invoice Number

                     Application for Certified Copy of Death Certificate
                   Information about person whose death certificate is being requested - please type or print.
                         First                             Middle                                 Last
  Full name of
   deceased
                         Month                             Day        Year          Age at Death         State of Birth
  Date of death

                         City                              County                                        State of Death
  Place of death

                                                                                                         Today’s Date
  Reason for Request

 Pursuant to Colorado Revised Statutes, 1982, 25-2-118 and as defined by Colorado Board of Health Rules and Regulations, applicant
 must have a direct and tangible interest in the record requested. The penalties for obtaining a record under false pretenses
 include a fine of not more than $1,000, or imprisonment in the county jail for not more than one year or both such fine and
 imprisonment.

By signing below, I have read and understood that there are penalties for obtaining a record under false pretenses. All requests must be
accompanied by a copy of the requestor’s identification before processing. PLEASE RETURN YOUR REQUEST WITH A PHOTOCOPY
OF YOUR DRIVERS LICENSE, STATE ID OR PASSPORT. Full list of Primary and Secondary Identification listed on other side.*

 Signature of person making request                                                    Your Relationship to deceased
 X
 Drivers License #                                     State of License                                     Expiration Date


 Address                                       City                 State               Zip                 Daytime Phone
                                                                                                             (             )

Make check or money order payable to Health Department. Please do not send cash through the mail. Additional funds received of
$5.00 or less will not be refunded unless requested in writing.
Ways     Office hours are from 8:00 - 4:30 Monday - Friday
to       Apply in person for same day service. Cash, checks and money orders accepted.
Order:   Mail in request, certificate will be mailed within three-four business days.
         Genealogy request will be mailed within two weeks. Pueblo County has death certificates from 1903 to present.
         For genealogy research, years available are 1887-1902.
Cost:    $17.00 for first copy (or search of files when no record is found).
         $10.00 for each additional copy ordered at the same time, for the same certificate. For genealogy purposes, if the
         year is unknown, there is the initial $17.00 fee plus $1.00 for every year requested to search thereafter.
         Credit card orders accepted by ordering online at www.vitalchek.com
                                                                                                        Office Use Only!

                                                                                              Today’s Date _________________________

                                                                                              Number of Copies _____________________

                                                                                              Total Amt. Due $______________________

                                                                                              Free Certificate Issued to: ______________

                                                                                              ID Copied _________ Issued By ________
                                                                                                              Staff Initials               Staffb Initials


                                                                                              $                   $                    $
                                                                                                    Cash                       Check          Total
 (Right to the Record) Birth, death and fetal death certificates are confidential in the State of Colorado. These records are
 not public records and, therefore, are not subject to the Freedom of Information Act. Proof of relationship is required.

Certified copies of death and fetal death certificates may be issued to the following with proof of direct and tangible interest:
Anatomical Board                                                              Hospital/Nursing Home/Hospice/Physician
Children/Grandchildren/Great grandchildren                                    Informant
Current spouse, Ex-spouse                                                     In-laws/aunts/uncles/nephews/nieces/cousins
Consular Corps/Consulate Offices                                              Insurance companies
Coroners                                                                      Legal Representative/Paralegals
Creditors                                                                     Opposing Counsel
Employer                                                                      Parent, Shared Parentage, Stepparent
Funeral Directors                                                             Probate Researchers
Genealogists                                                                  Siblings/Half siblings
Governmental Agencies (SSA, Human Services, etc)                              Step-Children
Grandparents/Great grandparents

                              Identification and Proof of Relationship is Required
    Documents not containing an issue or expiration date are not acceptable. If you cannot provide acceptable identification, it is
    suggested that you ask a spouse, parent, grandparent, sibling, or adult child, who can provide appropriate identification, to
    request the certificate. Proof of Relationship is Required, such as a birth certificate or marriage certificate.

 At least 1 of the following:         (No expired documents accepted)
Alien Registration Receipt or Permanent Resident card                             Photo ID Card
Certificate of U.S. Citizenship                                                   School, University or College ID Card (current)
CO Department of Corrections ID Card                                              Temporary Resident Card
CO Temporary Driver’s License Form                                                U.S. B1/B2 Visa card with I-94
(with hole-punched CO Driver’s License)                                           U.S. Certificate of Naturalization
Employment Authorization Card (I-766)                                             U.S. Citizenship ID Card (I-197)
Foreign Passport                                                                  U.S. Military ID Card
Photo Driver’s License                                                            U.S. Passport

Or at least 2 of the following: (Documents expired more than six months will not be accepted)
Acknowledgement of paternity document             Selective service card                      Lists are subject to change!
Birth certificate of the applicant (U.S. only)    Social security card
CO Temporary Drivers License Renewal Form         Social service card
(Expires 30 days from issuance)                   State, territorial or federal
Court order of adoption or name change            prison or correction card         Office Use Only!        (Proof of Relationship)
Craft or trade license                            Tribal ID Card
DD-214                                            Voter registration card
Divorce Decree (U.S. only)                        Weapon or gun permit
Hospital birth worksheet (for infants under 6                                      Birth Name of Person Requesting Certificate
                                                  Work ID, Paycheck Stub or
months)                                                                            Date of Birth _____________________________
                                                  W-2
Hunting/Fishing license (current)                                                  Maiden Name____________________________
IRS-TIN card                                                                       SF # ___________________________________
                                                  List Updated 10-1-09
Marriage license (U.S. only)
Medicare Card
Merchant mariner card                                                              Birth Name of Person Requesting Certificate
Mexican voter registration card                                                    Date of Birth ____________________________
Motor vehicle registration or title (U.S.only)                                     Maiden Name ___________________________
Non-Expiring State ID cards                                                        SF # ___________________________________
Pilot License
Probation Documents
Property tax receipt
                                                                                    Birth Name of Person Requesting Certificate
                                                                                    Date of Birth ____________________________
                                                                                    Maiden Name ___________________________
Colorado Department of Health and Environment, Vital Records Section                SF #___________________________________
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Telephone 1-303-692-2200, www.cdphe.state.co.us                                       Death Application & Picture ID Final Revision 11-03-2010

								
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