Bureau of Vital Records Request for Copy of Death Certificate
Please visit the Bureau of Vital Records website www.azhealth.gov for the following information:
• Fees• Locations, office hours, and availability of services• Eligibility requirements and acceptable identification• Correction, amendment, and registration information• Download forms
Telephone: 602-364-1300Apply Online: www.VITALCHEK.com (Refer to website for their current fees)
CUSTOMER ChECkliST 2 Clear photocopy of the front and back of your valid, signed
government photo ID OR have your signature notarized
2 Proof of relationship enclosed if required (birth certificates, certified court documents, marriage certificate, etc)
2 Sign the application
2 Include self-addressed stamped envelope
2 Correct fee enclosed
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Today's Date
Applicant's Full Name — Printed
First Middle last
APPliCANT'S SiGNATURE — REQUiRED
Date of Death
Place of Death — hospital or Residence
City County State
Name on Death Certificate
First Middle last
Mailing Address
Street City State Zip
# of Certified Copies Requested
Genealogy # of Noncertified Copies Requested
Purpose of Request Payment Method
Sex
2 Male 2 Female
Daytime Telephone Number Email Address
Your Relationship to Person on Certificate — Check One *PROOF of relationship MUST be provided. 2 Parent 2 Relative 2 Grandparent 2 Spouse 2 Gov't Agency 2 Other 2 Legal Interest (Beneficiary, Insurance Policy, Will, Personal Representative, Property, etc.)
Documentation must be provided to support this legal interest.
State of County of
On this day of , 20 before me personally appeared
(name of signer), whose identity was proven to me
on the basis of satisfactory evidence to be the person whose name is subscribed to this document, and who
acknowledges that he/she signed the above document.
Notary Signature My Commission Expires
Affix Seal/Stamp Here
Payment information
Card Number _______ - _______ - _______ - _______ Card Expiration Date / 2 Visa 2 MC
Signature of Cardholder — Must provide photocopy of valid government issued identification if cardholder is not the applicant. Amount to be Charged
$
For Office Use Only — State File Number / Serial Number
VS-158 (10/16)
Request iD
iNFO
2 Death 2 Fetal Death2 Stillbirth
Funeral home or Donation Facility
if Yes, list Claim (SSA, VA, ETC.)
Are Copies to be used for Government Claim?
2 Yes 2 No
Social Security Number Date of Birth
2 Hospital 2 Residence2 Other
