Version 12/2020
2 Click to Clear Form___
Alaska DEATH Certificate Request Form
• Please read the instructions on the first page. Incomplete or inaccurate requests that do not include a copy of a government issued ID will not be
processed.
• Submit this form WITH PAYMENT in person (Cash, check, money order or credit card), by mail (check, money order, or credit card), or by fax (credit
card only). Office locations and contact information are on the instruction page.
• Please make Checks/Money Orders payable to: ALASKA VITAL RECORDS OFFICE.
• There will be a $30 nonsufficient funds fee for returned checks.
Information needed to locate the record:
FIRST Name of the Deceased (at time of death)
_________________________________________________________
MIDDLE Name of Deceased
_________________________________________________________
LAST/FAMILY Name of Deceased
_________________________________________________________
Date of Death _____________________________________________
Date of Birth of Deceased ___________________________________
City/Village of Death
_______________________________________
Full Name of Deceased’s Mother Prior to Marriage
_________________________________________________________
Full Name of Deceased’s Father
_________________________________________________________
APPLICANT NAME _____________________________________________
Contact Phone N
umber
_________________________________________
Contact E-mail Address_______________________________
Mailing Name _________________________________________________
Mailing Address:
Street/P.O. Box________________________________________________
City, State, Zip ____________________________________
Purpose of Request: Ex: Personal records, legal purpose, government
benefits, etc.
_____________________________________________________________
Your Relationship to the deceased:
___ Legal representative (with documentation)
___ Other (Please specify) ______________________________________
Signature of Person Requesting the Record (Electronic/Typed Signature NOT
Accepted)
_____________________________________________________________
What would you like to order?
Fee:
_____ Number of Certified Death Certificates _______
($30 for one copy plus $25 for each additional copy of the same record ordered at the same time)
_____ ________
_____ ________
_________________________
________
____
_______
_______
_____ _______
____ _______ _
___________________________________
_________________________________
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Death Certificate Correction Processing Fee ($30)
Apostille Fee ($12 for first copy, $2 for each additional copy)
Apostille Country:
_____ *Expedited/Rush Service (Fax/Email orders) ($11)
How would you like it shipped?
Please note: Alaska Vital Records assumes no responsibility for items after they have been shipped. If documents are lost or
stolen you will need to resubmit your order with ID and payment. Vital Record certificates are legal documents that should be
in your control only. Lost certificates may end up in the hands of criminals who could use the certificate to steal your identity.
HAVRS strongly recommends you choose a method of shipping that requires a signature upon receipt. Call 907-465-3391 for
more information on International Shipping.
Choose one:
_ Regular Mail (No fee, NO tracking available!)
_____
_______
Priority Mail ($9.00. Includes tracking. No signature required).
_____ Priority Mail ($12.00. Includes tracking and signature).
FedEx Alaska (No P.O. Boxes; $25.00. Includes tracking and signature).
Do You Want a Signature?
Yes No
FedEx USA (No P.O. Boxes; $30.00. Includes tracking and signature).
Do You Want a Signature?
Yes
No
Total for all Items
Credit Card Information
(We accept: Visa, MasterCard, Discover, and American Express)
Name on Credit Card
Credit Card Number
E
xpiration date ________
_____________________________
Zip Code __________________________________________________
Cardholder Sign
ature (REQUIRED; ELECTRONIC/TYPED SIGNATURE NOT
ACCEPTED)
___________________________________________________________
