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ALPINE COUNTY APPLICATION FOR CERTIFIED COPY OF DEATH RECORD DO NOT Complete This Application Before Reading the Instructions on Page 2 In an attempt to stop the illegal use of vital records, and as part of statewide efforts to reduce identity theft, a new law (effective July1, 2003) changed the way certified copies of birth certificates are issued. Certified Copies to establish the identity of a registrant can be issued only to authorized individuals, as indicated below. All others will be issued Certified Informational Copies that are not valid to establish identity. Fee: $16 per copy payable to the Alpine County Recorder Please indicate the type of certified copy you are requesting: I would like a Certified Copy. This copy will establish the identity of the registrant. (To receive a Certified Copy you MUST INDICATE YOUR RELATIONSHIP TO THE REGISTRANT by selecting from the list below AND COMPLETE THE ATTACHED SWORN STATEMENT declaring that you are eligible to receive the Certified Copy. The Sworn Statement MUST BE NOTARIZED if the application is submitted by mail unless you are a law enforcement or local or state governmental agency.) I would like a Certified Informational Copy. This document will be printed with a legend on the face of the document that states, “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” (A Sworn Statement does not need to be provided.) NOTE: Both documents are certified copies of the original document on file with our office. With the exception of the legend, the documents contain the exact same information. To receive a Certified Copy I am: A parent or legal guardian of the registrant (person listed on the certificate). A party entitled to receive the record as a result of a court order. A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting official business. (Companies representing a government agency must provide authorization from the government agency.) A child, grandparent, grandchild, brother or sister, spouse, or domestic partner of the registrant. An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a court to act on behalf of the registrant or the registrant’s estate. (If you are requesting a Certified Copy under a power of attorney, please include a copy of the power of attorney with this application form.) Any agent or employee of a funeral establishment who acts within the course and scope of his or her employment and who orders certified copies of a death certificate on behalf of an individual specified in paragraphs to inclusive, of subdivision of Section 7100 of the Health and Safety Code. PLEASE TYPE OR PRINT THE INFORMATION REQUESTED BELOW EXCEPT WHERE SIGNATURE IS REQUIRED APPLICANT INFORMATION (PLEASE PRINT OR TYPE) Today’s Date: Agency Name (if appropriate) Agency Case No. Purpose of Request Printed Name and Signature of Applicant Daytime Telephone Number (include area code) Mailing Address – Number, Street City State ZIP Code Name of Person Receiving Copies, if Different From Applicant Number of Copies Amount Enclosed Purpose of Request Mailing Address for Copies, if Different From Applicant City State ZIP Code DECEDENT INFORMATION: (PLEASE PRINT OR TYPE) Name of Decedent-Last FIRST MIDDLE Sex City of Death (must be in California) County of Death Date of Birth- MM/DD/CCYY State of Birth Date of Death-MM/DD/CCYY Social Security Number BIRTH Name –Mother/Parent Birth Name of Spouse/Domestic Partner of Decedent (Last, First Middle) DEATH Page 1 of 3 VS 112 (01/2008) ---PAGE BREAK--- INFORMATION: Death records have been maintained in the Office of the State Registrar of Vital Records since July 1, 1905. The “Birth” name required on Vital Records (see Items 1C, 6C, 7C, 9C and 12C) is the name given at birth, or a name received through adoption, court ordered name change, or Naturalization. AKA’s (Also Known As) and assumed names cannot be entered as the legal “Birth” name. INSTRUCTIONS: 1. As of July 1, 2003, ONLY individuals who are authorized by Health and Safety Code Section 103526 can obtain a Certified Copy of a Death Record. (Page 1 identifies the individuals who are authorized to make the request.) All others may receive a Certified Informational Copy which will be marked, “Informational, Not a Valid Document to Establish Identity.” 2. Complete a separate application for each death record requested. 3. Complete the Applicant Information section on Page 1 and provide your signature where indicated. In the Decedent Information section, provide all the information you have available to identify the death record. If the information you furnish is incomplete or inaccurate, we may not be able to locate the record. 4. SWORN STATEMENT: • The authorized individual requesting the certified copy must sign the attached Sworn Statement, declaring under penalty of perjury that they are eligible to receive the certified copy of the death record, and identify their relationship to the registrant (person listed on the certificate) – the relationship must be one of those identified on Page 1. • If the application is being submitted by mail, the Sworn Statement must be notarized by a Notary Public. (To find a Notary Public, see your local yellow pages or call your banking institution.) Law enforcement and local and state governmental agencies are exempt from the notary requirement. • You do not have to provide a Sworn Statement if you request a “Certified Informational Copy” of the death record. 5. Submit $16 for each copy requested. If no death record is found, the $16 fee will be retained for searching the record (as required by law) and a Certificate of No Public Record will be issued to applicant. Indicate the number of copies you want and include the correct fee(s) in the form of a personal check or postal or bank money order (International Money Order for out-of-country requests) made payable to the Alpine County Recorder. Mail this application with the fee(s) to the Alpine County Recorder at the address below. 6. Returning Completed Certificates: Completed certificates are returned using the U.S. Postal Service. Alpine County Recorder P.O. Box 155 Markleeville, CA 96120 (530) 694-2283 DEATH Page 2 of 3 VS 112 (01/2008) ---PAGE BREAK--- SWORN STATEMENT I, declare under penalty of perjury under the laws of the State of California, (Applicant’s Printed Name) that I am an authorized person, as defined in California Health and Safety Code Section 103526 and am eligible to receive a certified copy of the birth, death, or marriage certificate of the following individual(s): Name of Person Listed on Certificate Applicant’s Relationship to Person Listed on Certificate (Must Be a Relationship Listed on Page 1 of Application) (The remaining information must be completed in the presence of a Notary Public or Office of Vital Records staff.) Subscribed to this day of at (Day) (Month) (City) (State) (Applicant’s Signature) Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of Acknowledgment below. The Certificate of Acknowledgement must be completed by a Notary Public. (Law enforcement and local and state governmental agencies are exempt from the notary requirement.) CERTIFICATE OF ACKNOWLEDGMENT State of ) County of On me, personally appeared (here insert name and title of the officer) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct WITNESS my hand and official seal. (SEAL) SIGNATURE VS 112 (01/2008) Page 3 of 3