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NOTICE: STATE LAW PROVIDES PENALTIES FOR PERSONS WHO WILLFULLY AND KNOWINGLY USE OR FURNISH TO ANOTHER FOR USE FOR ANY PURPOSE OF DECEPTION, ANY CERTIFICATE, RECORD REPORT, OR ANY CERTIFICATE, RECORD REPORT, OR CERTIFIED COPY MADE, ALTERED, AMENDED OR MUTILATED. (50-15-114, MCA) BUTTE-SILVER BOW CLERK AND RECORDER’S OFFICE REQUEST FOR DEATH CERTIFICATES PLEASE READ THESE INSTRUCTIONS CAREFULLY WHO CAN ORDER A DEATH CERTIFICATE Complete copies of a certified death certificate will be issued to anyone who submits a completed application, establishes their identity, and lists the reason for needing the copy. If a death certificate lists the cause of death as “pending autopsy” or “pending investigation”, a certified copy which has the cause of death information removed will be issued. IDENTIFICATION IS REQUIRED The person signing the request must provide an enlarged legible photocopy of both sides of their valid driver’s license or other legal picture identification with a signature or the requestor must have this application notarized. REQUIRED IDENTIFICATION PICTURE ID WITH A SIGNATURE OR TWO FORMS OF ID – ONE MUST HAVE A SIGNATURE OR • Drivers license • State ID Card • Passport • Military ID Card • Tribal • Social Security card • Work ID card • Car registration/insurance • Doctor/Medical record • Fishing License • US Military DD214 • Utility bill with a current address • Voter Registration card • Credit/Debit/ATM card • School ID card • Library card • Insurance record • Pay stub • Traffic/pawn ticket • Court record • Year book Notarized Montana Office of Vital Statistic Statement to Identify certified Birth or Death Certificate Applicant Form (you must provide the original letter, not a photocopy or faxed copy) Have authorized family member that has an ID order the certificate If a picture ID with a signature is not available, two other forms of identification are required, one MUST have a signature. Please include photocopies of both sides of the ID when mailing your request. IMPORTANT: If the identification requirement is NOT met or if the application is incomplete, your request will be returned and significant delays in processing your order may occur. FEE (All fees must be U.S. funds) CERTIFIED COPIES OF A DEATH CERTIFICATE: cost $3.00 for each copy (non-refundable) INFORMATIONAL COPIES OF A DEATH CERTIFICATE: the cost is $0.50 (non-refundable) SEARCHES: $0.50 for each year searched. (An informational copy will be issued if a record is found) (non-refundable) Please complete the following information: DECEDENTS Name: Date of Death: (We need a year to begin searching if exact date is unknown) Place of Death: (City or county) Date of Birth: Place of Birth: Mother’s Full Name: Father’s Full Name: Decedents Occupation: Spouse’s Name: Number of Copies Requested: Type of copy needed: Certified _ Non Certified ($0.50) _ Reason Record is Needed: Relationship to Decedent: Signature of Applicant: Mailing or delivery address: Name: Address: City, State, Zip: Telephone Number: Email Address: RETURN FORM(S), MONEY ORDER OR CASH (only) & STAMPED SELF ADDRESSED ENVELOPE TO: BSB CLERK & RECORDER’S OFFICE RM 208 155 WEST GRANITE BUTTE, MONTANA 59701 Notary (if needed) Personally appeared before me and whose identity I proved on the basis of satisfactory evidence to be the signer of the above instrument. Subscribed and sworn to before me this day of 20___ Official Use Only SEAL Signature: Printed Name: Notary Public in and for the State of Residing at My commission expires Date: Rec Cert Ser