DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-05280 (Rev. 05/2018)
STATE OF WISCONSIN
Wis. Stat. § 69.21
Page 1 of 2
WISCONSIN DEATH CERTIFICATE APPLICATION
(for Mail or In-Person Requests)
PENALTIES: Any person who illegally possesses any vital record with knowledge that the vital record has been illegally obtained is guilty of a Class I felony [a fine of not more than
$10,000 or imprisonment of not more than 3 years and 6 months, or both, per Wis. Stat. § 69.24(1)].
MAIL TO NAME - First (if different)
YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No.
MAIL TO ADDRESS (if different than street address) Apt. No.
DAYTIME TELEPHONE NUMBER
( )
TYPE OF CURRENT VALID PHOTO ID
(See item 4, on page 2.)
II. APPLICANT’S RELATIONSHIP TO
PERSON NAMED ON THE CERTIFICATE
Per Wis. Stat. § 69.21, a CERTIFIED copy of a death certificate is available to applicants with a “direct and tangible interest." (A–D below)
CHECK ONE box which indicates YOUR RELATIONSHIP to the PERSON NAMED on the death certificate.
A. I am a member of the immediate family of the person named on the death certificate.
Parent (My name is on the death certificate and my parental rights have not been terminated.)
Brother / Sister Current Spouse Child
Maternal Grandparent Paternal Grandparent Current Domestic Partner (registered in the Wis. Vital Records System)
B. I am the legal custodian or guardian of the person named on the death certificate.
C. I am a representative authorized by any person in category A or B, including an attorney.
Specify the person you represent: ____________________________________________________________________________________
D. I can demonstrate the death certificate is necessary for the determination or protection of a personal or property right.
Specify your interest: ______________________________________________________________________________________________
E. I am a direct descendent of the decedent and am requesting an uncertified copy of the death certificate.
F. None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity purposes.)
NOTE: Stepparents, stepchildren, stepbrothers / stepsisters may only obtain certified copies as categories B–D.
PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:
FIRST COPY FEE ………………………….……………………………………………………………….………………....…… $ 20.00 ___$20.00__
Fact of Death (without cause of death, manner of death, and final disposition) (sufficient for most financial transactions)
OR Extended Fact of Death (with cause of death, manner of death, and final disposition) (for insurance benefit claims)
EACH ADDITIONAL COPY (issued at the same time as the first copy)
Fact of Death ………………………………………………………....………….….. _____________________ X $ 3.00 ___________
Number of Additional Copies
Extended Fact of Death …………………………………………..………….……… _____________________ X $ 3.00 ___________
Number of Additional
TOTAL
Submit your application materials and fee to:
Be sure to include: completed form, acceptable identification, payment,
any additional proof or authorization required
IV. DEATH RECORD
INFORMATION
DATE OF DEATH (MM/DD/YYYY)
PLACE OF DEATH – City, Village, or Town *
DECEDENT’S SOCIAL SECURITY NUMBER *
DECEDENT’S AGE / BIRTHDATE *
NAME OF DECEDENT’S SPOUSE *
NAME OF DECEDENT’S PARENT *
NAME OF DECEDENT’S PARENT *
I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies of
the requested death certificate in accordance with the categories listed above.
Important: Signature and payment are required for processing.
*The fields marked with an asterisk (*) do not have to be completed. The information is helpful but not required.
Register of Deeds, 1101 Carmichael Rd, Hudson, WI 54016
and a self addressed, stamped, business-size envelope
