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Park County Clerk & Recorder 855 Castello Avenue, P.O. Box 220 Fairplay, CO 80440 7 L9-836-4225 17 Lgl 83 6-4348 fax Application for Certified copy of Death Certificate Req uire ments This request must be completed in full. Enclose a copy of a current driver's license, passport or state identification (the complete list of primary and secondary lD's are available on line at www.colorado.gov/cdphe) Enclose approprlate fees. Person requesting to receive death certificate must sign below. Proof of relationship or legal interest is required Requestor lnformati6n (Please Print) DeCeaSgd lnfOfmatiOn E Cnecf here if you are requesting a certificate of stillbirth PAYMENT BY CASH OR MONEY ORDER ONLY Name ol person making requesl First Middle Last Email Mailing Address City State zip Daytime Phone Physical Address City State zip Alt Phone Number Relationship to deceased E parent E Spouse (must submit proof of relationship) E tegal Representative *see reverse side Q Grandparent E siuting u other: E CfritO E Funeral Director Reason for Request: E lnsurance E Social Security E property E Genealogy E Ottrer Full name of deceased First Date of death* (or range of dates) Month Day Date of birth or age at death (optional) State of birth (optional) Place of death City uounty 5tate Colorado ONLY Pursuant to Cotorado Revised Statutes,1982,25-2-118 and as defined by Cotorado Board of Heatth Rutes and Regutations, applicant must have a direct and tangibte interest in the record requested. The penatties for obtaining a record under false pretenses include a fine of not more than S1,000.00, or imprisonment in the county jait for not more than one year or both such fine and imprisonment (CRS 25-2-1 18). By signing below, I have read and understand that there are penalties for obtaining a record under false pretenses. @ lroaav's oate Search fee where date of death is unknown ($1.00 per year) ...S20.00 = S Cost ofdeath certlficate: 520.00 for one (or search when no record found) First copy-check one: _ Standard death certificate (entire record) .S20.oo = ( _ Legal death certificate (all legal and no mehical) _Verification of death (limited legal information and no medical information.... S20.00 =q Cost of additlonal certificates: S13.00 _ Standard death certificate (entire record) x S13.oo =q -Legaldeathcertificate(alllegalandnomedical).''........-x$la.oo=s- -Verificationofdeath(limitedlegalandnomedical),,;;;-x$r:.oo=S-