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Alpine County Recorder APPLICATION FOR CERTIFIED COPY OF DEATH RECORD PLEASE READ THE INSTRUCTIONS ON PAGE 3 BEFORE COMPLETING THIS APPLICATION California law (Health and Safety Code Section 103526), permits only authorized individuals as listed on the application to receive certified copies of death records. Those who are not authorized by law to receive an authorized certified copy will receive a certified informational copy with the legend, “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” Please indicate the type of certified copy you are requesting: I am requesting a Certified AUTHORIZED copy I am requesting a Certified INFORMATIONAL copy NOTE: Both documents are certified copies of the original document on file with the Alpine County Recorder – Vital Records With the exception of the legend and redaction of signatures and Social Security Number, the documents contain the same information. To receive an AUTHORIZED copy, you MUST INDICATE YOUR RELATIONSHIP TO THE REGISTRANT below. To receive a certified copy, the applicant must sign a sworn statement that he or she is authorized to receive the certified copy. The Sworn Statement MUST BE NOTARIZED unless you are a member of a law enforcement agency or representative of a state or local government agency, an agent or employee of a funeral establishment. RELATIONSHIP: Child/Sibling of Registrant Spouse/Registered Domestic Partner of Registrant Grandparent/Grandchild of Registrant Attorney Representing Registrant or Registrant’s Estate Authorized by Court Order (Include copy of the court order.) Law Enforcement/Govt. Agency (Conducting Official Business) Parent/Legal Guardian of Registrant (Dust provide documentation.) An Agent or Employee of a Funeral Establishment (Acting within the scope of employment and on behalf of persons specified in HSC §7100 Power of Attorney/Executor of the Registrant’s Estate (Include a copy of the power of attorney or documentation identifying you as executor.) APPLICANT INFORMATION (PRINT OR TYPE) Today’s Date: Agency Name (If Applicable) Agency Case Number Inmate ID Number Name of Person Completing Application Signature of Applicant Purpose of Request ܆Check this box for CNPR Mailing Address – Number, Street, and Unit # (if applicable) Amount Enclosed – DO NOT SEND CASH $ Check $ Money Order Number of Copies City Name of Person Receiving Copies if Different from Applicant State/Province ZIP Code Country Mailing Address for Copies if Different from Applicant Daytime Telephone Number ( ) Email Address City State ZIP Code DEATH RECORD INFORMATION (PRINT OR TYPE) Complete the information below as shown on the death record, to the best of your knowledge. Name of Decedent – FIRST MIDDLE LAST City of Death (must be in California) County of Death Date of Birth – MM/DD/YYYY State of Birth Date of Death – MM/DD/YYYY (If unknown, enter approximate date) Social Security Number Mother/Parent Name (First, Middle, Last) Name of Spouse/Domestic Partner of Decedent (First, Middle, Last) FEE: $21 PER COPY (ALPINE COUNTY RECORDER) Submit Check or Money Order – Do Not Send Cash Check/Money Order Enclosed Notarized Sworn Statement Enclosed (if applicable) DEATH VS 112 (1/1ϵ) Page 1 of 3 ;ŽƌĂƌĞůĂƚŝǀĞĚĞƐĐƌŝďĞĚŝŶ,^ΑϳϭϬϬ;ĂͿ;ϭͿͲ;ϴͿͿ ^ƵƌǀŝǀŝŶŐEĞdžƚŽĨ<ŝŶ;ƐƉĞĐŝĨŝĞĚŝŶ,^ΑϳϭϬϬͿ ---PAGE BREAK--- SIGN SIGN ---PAGE BREAK---