Fillable APPLICATION FOR DEATH RECORD (County of Los Angeles / Internal Services Department)

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APPLICATION FOR DEATH RECORD (County of Los Angeles / Internal Services Department)

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BROWSE COUNTY OF LOS ANGELES / INTERNAL SERVICES DEPARTMENT (CA) FORMS

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COUNTY OF LOS ANGELES y REGISTRAR-RECORDER/COUNTY CLERK, P.O. BOX 489, NORWALK, CA 90651-0489 (562) 462-2137
APPLICATION FOR DEATH RECORD
Pursuant to Health and Safety Code 103526, the following individuals are entitled to an AUTHORIZED Certified Copy
of a death record.
A member of a law enforcement agency or a representative of another governmental agency, as provided by
law, who is conducting official business.
A child, grandparent, grandchild, sibling, spouse or domestic partner of the registrant
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 funeral director or agent/employee of a funeral establishment acting within the scope of their
employment who orders certified copies of a death certificate on behalf of any individual specified in
paragraphs (1) to (5), inclusive of subdivision (a) of Section 7100 of the Health and Safety Code.
If applying in person the application must be signed in the presence of the cashier.
Those who are not authorized may receive an INFORMATIONAL Certified Copy with the words
"INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY" imprinted across the face of the
copy.
MAIL REQUESTS FOR AUTHORIZED COPIES MUST BE ACCOMPANIED BY A NOTARIZED CERTIFICATE OF IDENTITY
I am requesting an AUTHORIZED copy I am requesting an INFORMATIONAL copy
NUMBER OF COPIES
NUMERO DE COPIAS
Month/Mes Day/Dia Year/Año
Date of Death – Fecha De Defuncion
NAME OF DECEASED (first, middle , last) –NOMBRE DEL DIFUNTO (primero, segundo, apellido)
CITY OF DEATH – CIUDAD DE DEFUNCION
RELATIONSHIP TO REGISTRANT (SEE ABOVE) – PARENTESCO CON LAS PERSONA REGISTRADA (VEÁSE ARRIBA)
I ____________________________________ certify (or declare) under penalty of perjury under the laws of
the State of California that the foregoing is true and correct.
Date ___________________________ Signature__________________________________________________
DL/ID________________________
NAME/NOMBRE
STREET ADDRESS/NUMERO Y CALLE
CITY /CIUDAD STATE/ESTADO ZIP/ZONA POSTAL
76A639D Rev. 5/10
FOR RECORDER USE ONLY
File Number
Searched
Doubled
SPECIAL NOTICE TO VETERANS
You may be eligible for a free certified copy if you are applying for a veteran’s pension or certain other
Veteran’s Administration benefits.
(Section 6107, Government Code State of California)
THIS DOES NOT APPLY TO SOCIAL SECURITY AND OTHER CIVILIAN BENEFITS, EVEN IF YOU
ARE A VETERAN.
If you believe you qualify for a free certified copy under these provisions, complete the following
affidavit.
I hereby apply for a free certified copy of the record as shown on the reverse side and declare under
penalty of perjury that the free copy is to be furnished to
_______________________________________ in a claim for _________________________________
FEDERAL OR STATE AGENCY TYPE OF BENEFIT
___________________ ________________________________________ _____________________
DATE SIGNATURE OF VETERAN OR AUTHORIZED AGENT RELATIONSHIP OF AGENT
NUMBER-STREET
CITY STATE ZIP
Note: The free copy issued on this affidavit will bear the following wording:
This certified copy has been issued free of charge on the declaration under penalty of perjury that it is to be used in
a claim to the Federal Government or the State of California for veteran’s benefits.
76A639D Rev. 5/10
CERTIFICATE OF IDENTITY/SWORN STATEMENT - BIRTH, DEATH & PUBLIC MARRIAGE
In accordance with California State Law, the following identifying information is required to obtain a certified copy of Birth,
Death or Public Marriage Certificate. You must be one of the following to receive an authorized copy of a birth, death or
public marriage record, individual named on certificate, parent, child, legal guardian/custodian, grandparents, grandchild,
sibling, spouse/domestic partner, attorney for individual/estate of individual or representative of an adoption agency (birth
only), funeral director or agent/employee (death only).
This certificate must be signed in the presence of a Notary.
Name(s) on Certificate Relationship
I, , declare under penalty of perjury under the laws of the State of
(Print Name)
California, that I am an authorized person, as defined in California Health and Safety Code Section 103526(c), and am
eligible to receive a certified copy of the birth or death record for the individual(s) listed above.
Subscribed to the day of 20 , at , .
(Day) (Month) (City) (State)
(Signature)
CERTIFICATE OF ACKNOWLEDGEMENT
STATE OF CALIFORNIA )
) ss
County of )
On , before me personally appeared
(Insert name and title of officer here)
DEAN C. LOGAN
Registrar-Recorder/County Clerk
COUNTY OF LOS ANGELES
REGISTRAR-RECORDER/COUNTY CLERK
P.O. BOX 489, NORWALK, CALIFORNIA 90651-0489 - www.lavote.net
“Enriching Lives”
______________________________________, who proved to me on the basis of satisfactory evidence, to be the person
whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her
authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person
acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and
correct.
WITNESS my hand and official seal.
(NOTARY SEAL)
___________________________________
NOTARY SIGNATURE
R1995 Rev. 3/2010
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APPLICATION FOR DEATH RECORD (County of Los Angeles Internal Services Department)

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Completed 15 March 2021

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