PETITION FOR AMENDMENT OF Case No. ...............................................................................
A DEATH CERTIFICATE
COMMONWEALTH OF VIRGINIA VA. CODE § 32.1-269.1
In re: .................................................................................................................................... ..........................................................................................
NAME OF DECEDENT DATE OF DEATH
.............................................................................................................................. ............................................................................................................
PLACE OF DEATH (CITY OR COUNTY) CERTIFICATE NUMBER OR STATE FILE NUMBER
.............................................................................................................................................................................................................................................................
COUNTY OR CITY IN WHICH DECEDENT RESIDED AS OF THE DATE OF DEATH
[ ] The undersigned petitioner requests the court to issue an Order for Amendment of a Death Certificate
[ ] Changing the name of the deceased from ......................................................................................................................................... to
.............................................................................................................................. .
[ ] Changing the name of the deceased’s [ ] parent(s) or [ ] spouse
from
................................................................................................. to ............................................................................................................. .
from .....................
.......................................................
..................... to ................................................
.............
................................................ .
[ ] Changing the name of the informant from ....................................................................................................................................... to
.............................................................................................................................. .
[ ] Changing the marital status of the deceased from ......................................................................................................................... to
.............................................................................................................................. .
and, if applicable, [ ] add or [ ] delete ............................................................................................... as the deceased’s spouse.
NAME
[ ] Changing the place of residence of the deceased from
..................................................................................................................................................................................................................................
STREET ADDRESS CITY OR TOWN COUNTY STATE OR
(IF APPLICABLE) FOREIGN COUNTRY
to ............................................................................................................................................................................................................................ ,
STREET ADDRESS CITY OR TOWN COUNTY STATE OR
(IF APPLICABLE) FOREIGN COUNTRY
a jurisdiction outside the Commonwealth.
OR
[ ] The undersigned petitioner, having previously applied to the State Registrar for an amendment to a death certificate,
which application was denied, requests the Court to issue an Order compelling the State Registrar to amend the death
certificate. (Attach a copy of application and any supporting evidence submitted to State Registrar.)
.......................................................................................... ______________________________________________________________
DATE SIGNATURE OF PETITIONER
..............................................................................................................................
PRINT NAME OF PETITIONER
..............................................................................................................................
MAILING ADDRESS OF PETITIONER
..............................................................................................................................
Relationship of petitioner to deceased:
[ ] surviving spouse [ ] immediate family member
[ ] attending funeral service licensee
[ ] other reporting sou
rce
.......................................................................
Commonwealth/State of
........................................................................ [ ] City [ ] County of ...............................................................................
Acknowledged, subscribed and sworn to/affirmed before me this ................... day of ................................................................ , 20 ............
by .......................................................................................................................................................................................................................................................
PRINT NAME OF SIGNATORY
.......................................................................................... ______________________________________________________________
DATE [ ] CLERK [ ] DEPUTY CLERK
[ ] NOTARY PUBLIC My commission expires ...........................................
Registration No. ......................................................
FORM CC-1453 MASTER 07/17
