Fillable APPLICATION FOR A FLORIDA DEATH RECORD Florida Department (Florida Department of Health)

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APPLICATION FOR A FLORIDA DEATH RECORD Florida Department (Florida Department of Health)

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APPLICATION FOR A FLORIDA DEATH RECORD
Florida Department of Health - Volusia County
Office of Vital Statistics
Office Hours: Monday – Friday 8:00 – 4:45
All Florida Death Records are available from 2009 to current year.
Read the FRONT AND BACK of this application: 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.
SECTION A: DECEDENT INFORMATION
NAME OF DECEDENT
FIRST
MIDDLE
LAST
SUFFIX
ALIAS NAME (IF APPLICABLE)
IF MARRIED FEMALE, MAIDEN SURNAME (if known)
SEX
DATE OF DEATH
MONTH
DAY
ADDITIONAL YEARS TO BE SEARCHED
(Required only when exact year of death is not
known)
Indicate the range of years to be searched
PLACE OF DEATH
PLACE OF DEATH CITY OR TOWN
PLACE OF DEATH COUNTY
STATE FILE NUMBER (if known)
NAME OF SURVIVING SPOUSE AS
RECORDED ON DEATH RECORD
(if applicable and if known)
FIRST
MIDDLE
LAST
SUFFIX
SOCIAL SECURITY NUMBER
(if known)
FUNERAL HOME NAME
(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.
SECTION B: APPLICANT 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.
Applicant’s
Name
TYPE OR PRINT
FIRST, MIDDLE, LAST (INCLUDING ANY SUFFIX)
SIGNATURE OF APPLICANT
Applicant’s Signature
HOME PHONE NUMBER
( )
MAILING ADDRESS (INCLUDE APT. NO., IF APPLICABLE)
RELATIONSHIP TO DECEDENT
ALTERNATE PHONE NUMBER
( )
CITY
STATE
ZIP CODE
Funeral Director/Attorney as Applicant
for
Cause of Death Information
LICENSE/ BAR NUMBER
NAME OF PERSON REPRESENTED and THEIR RELATIONSHIP TO DECEDENT
SECTION C: CERTIFICATES AND FEES
Cost Quantity Total Cost
Certified Copy With Cause of Death $8.00 x ________ = $________
(Restrictions apply. See eligibility on reverse side of form.)
Certified Copy Without Cause of Death $8.00 x ________ = $________
Expedited Processing (Optional): $10.00 $________
(Only available for applications received by mail. See reverse side of form for instructions.)
Overnight Delivery (Optional): $10.00 $________
(See reverse side of form for instructions.)
Death Records Search Fee (As Needed): $3.50 x ________ = $________
(Only applicable for search when year of death unknown.)
TOTAL DUE = $________
FOR USE BY FDOH VITAL STATISTICS OFFICIALS ONLY:
Certificate #____________________ Applicant ID #____________________ Initials:__________
DH 1961 6/13 64V-1.0131, Florida Administrative Code (Obsoletes previous editions)
INFORMATION AND INSTRUCTIONS
AVAILABILITY: Death registration was not required by state law until 1917; however, it was many years before we had consistent
registration. While there are some records on file dating back to 1877, not all events were registered.
ELIGIBILITY:
WITHOUT CAUSE OF DEATH: Any person of legal age (18) may be issued a death certification without the cause of death.
CAUSE OF DEATH INFORMATION: Cause of Death for any record over 50 years old may be issued to any applicant.
Death records less than 50 years old with the cause of death information included may only be issued to the following
individuals:
Decedent’s spouse or parent;
Decedent’s child, grandchild or sibling, if of legal age;
Any person who provides a will, insurance policy or other document that demonstrates his or her interest in the
estate of the decedent, OR
Any person who provides documentation that he or she is acting on behalf of any of the above named persons.
Requests for a death certification that includes the cause of death information must state the qualifying eligibility, or a
notarized Affidavit to Release Cause of Death Information (DH 1959), which is available upon request. If after reading the
above information you are still uncertain regarding your eligibility for cause of death information, call our office (904) 359-6900
extension 9000 for assistance.
A funeral director or attorney representing an eligible person as defined above must include their professional license number,
and the name and relationship of the person they are representing, if requesting cause of death. If not representing someone
identified above as eligible to receive cause of death information, then a completed Affidavit to Release Cause of Death
Information (DH 1959) must accompany this request. SPECIAL NOTE: Florida clerks of court will not accept a death record
with cause of death information included when filing probate.
INFORMATION NEEDED: A search cannot be made without the decedent’s name and year of death. If any of the other items
requested on the front of this form are unavailable, other identifying information (such as parents’ names, birthplace, etc) may
be helpful if multiple records are found for common names.
APPLICANT’S SIGNATURE: Applicant’s signature is required, as well as his/her name, valid residence address and telephone
number.
OPTIONS FOR EXPEDITED SERVICES (Only Available for Mailed Applications):
Expedited Processing Fee: If you want to have your application expedited, please submit your application and marked the outside
of the envelope EXPEDITE with the $10.00 expedited processing fee enclosed. If the record and application are complete and in order,
the application will be processed and the certificate(s) will be mailed via U.S. Mail by the next business day.
Overnight Delivery Fee: If you would like to have your certificate(s) returned to you via FedEx (where available, some locations
require a two-day delivery which is determined by FedEx based on delivery address), please include an additional $10.00 Overnight
Delivery Fee with your application and $10.00 expedited processing fee, for a total of $20.00. If the record and application are
complete and in order, the application will be processed and the certificate(s) sent via FedEx the same business day (where available,
some locations require a two-day delivery which is determined by FedEx based on delivery address) the request was received. Adult
Signature is required at time of delivery.
Regular Mail Request: general processing time is 7 to 10 business days for non-expedited mail request.
PAYMENT OPTIONS FOR SERVICES:
Payments made with mailed in request: If you are sending your
request to this office, payments accepted are money order or
check (starter checks are not acceptable). Please make your payment
out to the following, Florida Department of Health – Volusia County.
Please do not send cash through the mail.
Payments made in person: If you are coming into the Vital Statistics
Office to request your certificate, payments accepted are cash, credit
cards (all major credit cards are accepted), money order and checks (starter checks are not acceptable).
Please make your payment out to the following, Florida Department of Health – Volusia County.
Mailing address: Florida Department of Health – Volusia County
Office of Vital Statistics - Bin #102
P.O. Box 9190
Daytona Beach, FL 32120
Telephone# : 386-274-0614
Website: www.volusiahealth.com
DH 1961 6/13 64V-1.0131, Florida Administrative Code (Obsoletes previous editions
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Completed 14 June 2022

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