V03 (01/01/2019)
Please wait 3 weeks from the date of the event before submitting your request. If we cannot identify the record based on the information provided,
Law requires that we retain the fee and issue a “Letter of No Record”. You will be asked to present a valid photo ID for all in-person requests.
I am:
A parent, legal guardian, child, grandparent, grandchild, sibiling, spouse, or domestic partner of the registrant (decedent indentified
on the certificate).
A party entitled to receive the record as a result of a court order. (Include a certified copy of the COURT ORDER)
A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business.
An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a
court to act on behalf of the registrant or the registrant’s estate.
Any agent or employee of a funeral establishment who acts within the scope of his or her employment and who orders certified
copies of a death certificate on behalf of any individual specified in (1) to (5), inclusive of Health and Safety code 7100(a).
An individual described in paragraph (1) to (8), inclusive, of subdivision (a) of Health and Safety Code 7100. Agent under power of
attorney for health care, competent surviving spouse, surviving competent adult child, surviving competent parent, surviving
competent adult sibling, surviving competent adult person respectively in the next degrees of kinship, or conservator.
DEATH INFORMATION ON CERTIFICATE (PLEASE PRINT OR TYPE) - $21.00 for each certified copy
First Name Middle Name Last Name
Date of Death County of Death No. of Copies
FOR OFFICIAL USE ONLY
COUNTY OF SAN DIEGO
ERNEST J. DRONENBURG, JR.
ASSESSOR/RECORDER/COUNTY CLERK
www.sdarcc.com
APPLICATION FOR A
DEATH CERTIFICATE OR
LETTER OF NO RECORD
$21.00 – PER COPY
FEES ARE NON-REFUNDABLE
FOR OFFICIAL USE ONLY - IN PERSON REQUEST
Type of identification provided:
[ ] Driver’s License [ ] Military ID
[ ] Passport [ ] Other ___________
Per California State Law, Health and Safety Code, Section 103526(c), permits only
authorized persons as defined below to request certified copies of Death Records.
Those who are not authorized by Law to receive a certified copy will receive a certified
informational copy marked “INFORMATIONAL, NOT A VALID DOCUMENT TO
ESTABLISH IDENTITY.”
I would like a Certified Copy of the record identified on the
application form. (In order to receive a Certified Copy, you must
indicate your relationship to the person named on the
application form by selecting from the list below.)
I would like a Certified Informational Copy of the record
identified on the application form. (You are not required to
select from the list below or complete the Statement of
Identity in order to receive an Informational Copy.)
STATEMENT OF IDENTITY F
OR AUTHORIZED PERSON - In Person Only
I,
____________________________________________, swear under penalty of perjury that I am an authorized person, as
indicated above, and am eligible to receive a certified copy of the death record identified on this application form.
Sworn this ________day of_______________, 20_______, at ___________________________________, ____________.
(Print Applicant Name)
PLEASE NOTE: IF SUBMITTING REQUEST BY MAIL
COMPLETE SWORN STATEMENT & CERTIFICATE OF ACKNOWLEDGMENT ON PAGE 2
For multiple mail requests only ONE Sworn Statement & Certificate of Acknowledgment is Required Per Applicant
(Day) (Month) (Year) (City) (State)
(Applicant's Signature)
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