Request for Death Certificate

H 105.102 REV
12103
DEATH
Pennsylvania
Department
(Records
By my signature below,
is complete and accurate
addition, I acknowledge
felony criminal penalties
Signature
Signature
PRINT
of person
required
or TYPE
DEATH
Application for Certified Copy of Death Record
of Health
available
I state I am the person whom I represent
and made subject to the penalties of 18
that misstating my identity or assuming
for identity theft pursuant to 18 Pa.C.S.
making
+
Division
of Vital Records
from 1906 to the present)
myself to be herein, and I affirm the information within this form
Pa.C.S. §4904 relating to unsworn falsification to authorities. In
the identity of another person may subject me to misdemeanor or
§4120 or other sections of the Pennsylvania Crimes Code.
request:
on ALL requests.
_
Must be 18 years of age or older to apply.
your name & CURRENT
If under
8, eligible requestor
must sign above.
address.
Relationship
Name:
to Person
Named on Certificate:
_----=~-O.---"-=--=-.:--------
Address:
City:
c--~-----
Daytime phone number:
(
)
Zip: ----
_
Intended
Use of Certified
Copy:
DSocial SecurityIBenefits
CEstate Settlement
DOther
(List reason:
DGenealogy
--..".
......0:...-=---=-:-
.)
PHOTO ID REQUIRED:
The individual requesting
the record must send a legib e-copy of his/her VALID
GOVERNMENT
ISSUED PHOTO ID with completed
pplication.
(Examples:
State issued driver's license or nondriver photo ID with requestor's
current address or passport.
{(possible
enlarge photo ID on copier by at least 150%.)
::;;
PRINT
or TYPE
information
below with regard
NameatDeath:
Date of Death:
of copies:
_
-7~L-----~~:__---------- Sex: CMaie
CFemale
0
person named on requested
certificate:
Number
-------;!-7----,-
(City/Bore/Township
(MonthIDay/Y ear
Social Security #:
----",:---""--_
_
in Pennsylvania)
Date of Birth:
_
Full Name of Father:
Funeral Director:---,c=---:i'-
....:.,:----'7-
_
DEATH: $ 9.00 each
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No fee may be required for deatfrrecords
Please complete the following:
Armed Forces Member's
Relationship
f active or inactive members
Name:
of the Armed Forces and their dependents.
Service Number:
to Armed Forces Member:
Rank and Branch of Service:
Iffee is required, make check! money order payable to: VITAL RECORDS. Complete this application and mail with
legible copy oUD to: Division of Vital Records, 101 South Mercer St., PO Box 1528, New Castle, PA 16101.
Please include a self-addressed stamped envelope.
You are welcome to visit one of our public offices in the following cities:
• New Castle, PA, Room 401, 101 South Mercer St.
• Philadelphia, PA, Philadelphia State Office Bldg,
Room 1009, 1400 West Spring Garden St.
• Pittsburgh, PA, Pittsburgh State Office Bldg,
• Erie, PA, 1910 West 26th St.
Room 512, 300 Liberty Ave .
• Harrisburg, PA, Health and Welfare Bldg;
• Scranton, PA, Scranton State Office Bldg, Room 112,
Room 129, 7th and Forster Sts.
100 Lackawanna Ave.
For ON-LINE
ORDERING
or additional
information,
Visit our website:
www.health.state.pa.us/vitalrecords
_