ALIAS NAME (if
applicable)
SOCIAL SECURITY
NUMBER if known
(if applicable and if
known)
Visa
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)
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.
LAST (Maiden, if applicable)
NAME OF SURVIVING SPOUSE AS RECORDED ON DEATH RECORD
STATE FILE NUMBER (if
known)
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
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.
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:
ADDITIONAL YEARS TO BE SEARCHED
MAILING ADDRESS (INCLUDE APT. NO., IF APPLICABLE)
SECTION A: DECEDENT INFORMATION
Funeral Director/Attorney as Applicant for Cause
of Deafth Information
NAME OF PERSON REPRESENTED
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.
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.
CVV# :
Expiration:
APPLICATION FOR A FLORIDA DEATH RECORD
(For Miami Dade County VITAL RECORDS Use Only)