Fillable APPLICATION FOR A CERTIFIED COPY OF DEATH CERTIFICATE (State of Nevada, Department of Information Technology)

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APPLICATION FOR A CERTIFIED COPY OF DEATH CERTIFICATE (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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Office of Vital Records and Statistics
4150 Technology Way, Suite 104 ● Carson City, Nevada 89706
775-684-4242 ● Fax 775-684-4156 ● dpbh.nv.gov/Vital Records
Page 1 of 1
APPLICATION FOR A CERTIFIED COPY OF DEATH CERTIFICATE OR VERIFICATION
C
ERTIFIED
C
OPY OF
D
EATH
C
ERTIFICATE
F
EE
:
$25.00 per certificate (Carson, Clark, Douglas, Lyon, Mineral and Washoe counties)
$22.00 per certificate (All other counties)
# of Copies
T
YPE OF
C
ERTIFICATE
(Please check one type box below
)
Certificate(s) to read as “Mother / Father”
Certificate(s) to read as “Parent / Parent”
VERIFICATION ONLY (
Verifies the existence of a record with the State of Nevada and does not include a certified copy.)
Search/Verification - $10.00 per search /verification
MAKE PAYMENT PAYABLE TO: Office of Vital Records. Checks, money orders and credit cards are accepted. Please include the “Authorization
for Credit Card Use” form and the card holder’s identification if paying by credit card. CASH FOR WALK-IN CUSTOMERS ONLY.
A
C
OPY OF THE
A
PPLICANT
’
S
P
HOTO
I
DENTIFICATION AND
F
ULL
P
AYMENT IS
R
EQUIRED FOR ALL
R
EQUESTS
.
P
ROOF OF
RELATIONSHIP IS REQUIRED FOR CERTIFICATE REQUESTS.
Name of the Person on the Certificate
Middle
Last
County of Death
Social Security Number
Parent’s First and Last Name
Last Name(s) Prior to First Marriage
Funeral Home / Mortuary in Charge of Arrangements
NRS 440.650 and NAC 440.070 requires the applicant to establish a direct relationship by blood or marriage, a legal relationship or a need
to facilitate a legal process to receive a certified copy of a certificate. Below, indicate your relationship or your legal need for this
certificate. Please provide proof such as a birth certificate or court order. Unless the applicant is the informant, listed surviving spouse, or
a parent listed on the certificate, the request will be rejected if sufficient proof is not provided. Visit our website listed below for more
information regarding proof required.
Relationship and Reason for Request
Applicant’s Printed Name
Applicant’s Signature
Applicant’s Address
(Street, City, State & ZIP)
Applicant’s Phone Number
FOR OFFICE USE ONLY
Receipt/Applicant ID Number:
Date:
Rev. 12/16/2019
Carson County - $25.00
Clark County - $25.00
Douglas County - $25.00
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APPLICATION FOR A CERTIFIED COPY OF DEATH CERTIFICATE (State of Nevada, Department of Information Technology)

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Completed 4 March 2021

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