NAME OF DECEDENT
SUFFIX
ALIAS NAME (if
applicable)
SEX
PLACE OF DEATH
SOCIAL SECURITY
NUMBER if known
(if applicable and if
known)
Applicant’s Name
TYPE OR PRINT
$20.00
X 1 =
$16.00
X =
YES NO
=
=
Only accepted:
Visa
Mastercard
Card Number:
LAST
MIDDLE
FIRST
SECTION B: APPLICANT (adult requesting certificate) INFORMATION
If requesting cause of death, all applicants must state their relationship to the decedent; if a funeral director or an attorney, you must enter the relationship of the person
you represent. Eligibility requirements are provided on the back of this form.
FIRST, MIDDLE, LAST (INCLUDING ANY SUFFIX)
SIGNATURE OF APPLICANT
Requirement for ordering: Anyone may apply for a death certification. When cause of death information is also requested and the death occurred less than 50 years ago, a
valid photo identification must accompany this application or if a mail request, a copy of the valid photo identification, front & back, must be provided; AND the applicant
OR person being represented must be an eligible person as outlined in statute (see Eligibility on the back of this form). Relationship to the decedent must be entered in the
space provided at the bottom of this form when requesting cause of death. If applicant is a funeral director or an attorney, see additional information under Eligibility on
back of this form to ensure proper completion of this application.
Acceptable forms of valid ID are: Driver's License, State Identification Card, Passport, and/or Military ID Card. When requesting a death certification
without cause of death OR if the death occurred over 50 years prior to the request, photo identification is not required.
FIRST
SUFFIX
NAME OF SURVIVING SPOUSE AS RECORDED ON DEATH RECORD
STATE FILE NUMBER (if
known)
PLACE OF DEATH COUNTY
MIDDLE
FUNERAL HOME NAME
FOR MAILING CREDIT CARD USERS ONLY (Applicant’s Name must match with Name on Credit Card) ID required
IF MARRIED FEMALE, MAIDEN SURNAME (if known)
IMPORTANT INFORMATION: Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382,
Florida Statutes, or on any application or affidavit, or who obtains confidential information from any Vital Record under false or fraudulent purposes, commits a felony of the
third degree, punishable as provided in Chapter 775, Florida Statutes.
(Required only when exact year of death is
not known)
Indicate the range of years to be
searched
PLACE OF DEATH CITY OR TOWN
DATE OF DEATH
MONTH
DAY
$
RUSH ORDERS (Optional): $10.00 per order. This option provides quick processing within the
Office of Vital Records only.
When purchased at the same time, additional copies of the identical death record are $
16.00 each.
Fee for one certified copy of a Florida death or search record is $ 20.00
TOTAL AMOUNT ENCLOSED: Certified checks or Money Orders only payable to Vital Records in US dollars. (PLEASE DO
NOT SEND CASH). Mail completed applications to: Vital Records Unit, 1350 NW 14
th
Street #101, Miami, FL 33125.
Number of Copies
AMOUNT DUE
$20.00
$
Total Due
Card Holder's Name:
DH 1961 6/13 64V-1.0131, Florida Administrative Code ( Obsoletes preious aditions)
How many with cause of death:
How many with/out cause of death:
YEAR
ADDITIONAL YEARS TO BE SEARCHED
RELATIONSHIP TO DECEDENT
MAILING ADDRESS (INCLUDE APT. NO., IF APPLICABLE)
SECTION A: DECEDENT INFORMATION
FEE/ORDERING INFORMATION
FEE
Funeral Director/Attorney as Applicant for Cause
of Deafth Information
ALTERNATE PHONE NUMBER
HOME PHONE NUMBER
ZIP CODE
STATE
CITY
LICENSE/ BAR No.
NAME OF PERSON REPRESENTED
RELATIONSHIP TO DECEDENT
DO NOT MAIL CASH OR PERSONAL CHECK *** MAKE MONEY ORDER PAYABLE TO: VITAL RECORDS
WALK-IN ONLY
8:00 A.M. to 4:00 P.M.
18255 Homestead Avenue
Miami, FL 33157
1350 NW 14th Street # 101
Miami, FL 33125
Tel. #305-575-5030
WALK-IN & MAIL ORDERS
8:00 A.M. to 4:00 P.M.
18680 NW 67th Avenue
Hialeah, FL 33015
Tel. #305-628-7230
WALK-IN ONLY
8:00 A.M. to 4:00 P.M.
Tel. # 305-278-1046
CVV# :
Expiration:
APPLICATION FOR A FLORIDA DEATH RECORD
(For Miami Dade County VITAL RECORDS Use Only)
Mail to:
Florida Department of Health
VITAL RECORDS UNIT
1350 NW 14
th
STREET, SUITE 101
MIAMI, FL 33125
Death certificates are available from 2009 to present. Death certificates older than 2009 can be obtained from the State Office of Vital
Statistics in Jacksonville at (904)359-6900 EXT.9000.
HTTP://MIAMIDADE.FLORIDAHEALTH.GOV/CERTIFICATES/INDEX.HTML
Decedent’s spouse or parent;
MAIL THIS APPLICATION WITH YOUR PAYMENT TO:
(PHOTO ID REQUIRED, NO PERSONAL CHECK ACCEPTED)
INFORMATION NEEDED: A search cannot be made without the decedent’s name and year of death. If any of the other items requested on the
front of this form are unavailable, other identifying information (such as parents’ names, birthplace, etc) will be needed.
APPLICANT’S SIGNATURE: Applicant’s signature is required, as well as his/her name, valid residence address and telephone number.
ELIGIBILITY:
MAILING INFORMATION
Decedent’s child, grandchild or sibling, if of legal age;
Any person who provides a will, insurance policy or other document that demonstrates his or her interest in the estate of the decedent, OR
Any person who provides documentation that he or she is acting on behalf of any of the above named persons.
Requests for a death certification that includes the cause of death information must state the qualifying eligibility, or a notarized Affidavit to
Release Cause of Death Information (DH 1959), which is available upon request. If after reading the above information you are still uncertain
regarding your eligibility for cause of death information, call our office (904) 359-6900 extension 9000 for assistance.
A funeral director or attorney representing an eligible person as defined above must include their professional license number, and the name
and relationship of the person they are representing, if requesting cause of death. If not representing someone identified above as eligible to
receive cause of death information, then a completed Affidavit to Release Cause of Death Information (DH 1959) must accompany this request.
SPECIAL NOTE: Florida clerks of court will not accept a death record with cause of death information included when filing probate.
INFORMATION AND INSTRUCTIONS
AVAILABILITY: Death registration was not required by state law until 1917; however, it was many years before we had consistent registration.
While there are some records on file dating back to 1877, not all events were registered.
WITHOUT CAUSE OF DEATH: Any person of legal age (18) may be issued a death certification without the cause of death.
CAUSE OF DEATH INFORMATION: Cause of Death for any record over 50 years old may be issued to any applicant. Death records less than 50
years old with the cause of death information included may only be issued to the following individuals:
VISIT OUR WEBSITE AT: