Fillable Application for North Carolina Death, Marriage or Divorce (North Carolina)

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Application for North Carolina Death, Marriage or Divorce (North Carolina)

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  • 15 check-boxes
  • 49 other fields

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File type: PDF

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Your Relationship to the Person Whose Certicate is Requested: (Check One)
Identication of the person requesting the certicate is required. See Page 2 for a list of acceptable IDs.
Self
Spouse (Current)
Brother/Sister
Child/Stepchild
Parent/
Stepparent
Grandparent
Grandchild
Authorized agent, attorney or legal representative
of the person listed (Proof REQUIRED)
Other (may not be entitled to a certied copy) Specify _______________________________________________________________________
North Carolina Department of Health and Human Services
Division of Public Health • N.C. Vital Records
https://vitalrecords.nc.gov
Telephone: 919-733-3000
Mail: NCOVR
Attn: Death, Marriage, Divorce
Certificate Order
1903 Mail Service Center
Raleigh, NC 27699-1900
Location: 225 North McDowell St. Raleigh,
NC 27603-1382
Application for North Carolina Death, Marriage or Divorce Record
A Death, Marriage or Divorce Certicate search costs $2
4 and includes one copy if a certicate is located. The search covers a three-year period.
This search fee is non-refundable. There is a fee of $15 for each additional certificate copy requested from the same search. If you want same-
day walk-in service, an additional $15 expedited processing fee is required. Make your certified check or money order payable to “N.C. Vital
Records.” Please do not send cash in the mail. Personal checks are not accepted. If you have questions, our telephone number is
919-733-3000.
Full Name of Deceased
Date of Death (Month/Day/Year) ________________ Age at Time of Death ____________ Race _______________________________
Location of Death (City or County)_____________________________________________________________
Date of Birth (Month/Day/Year)________________________________________________________________
Full Name of Groom/Applicant
Full Name of Bride/Applicant
Date of Marriage
(Month/Day/Year) _________________________________________________________
County Where License Was Issued __________________________________________________________
Full Name of Husband/Spouse
Full Name of Wife/Spouse
Date of Divorce (Month/Day/Year)__________________________________________________________
Location of Divorce (City or County)________________________________________________________
____________________________________________________________________
First Name Middle Name Last Name Last Name prior to rst marriage, if applies
____________________________________________________________________
First Name Middle Name Last Name Last Name prior to rst marriage, if applies
DHHS-VR-DMD (Revised 01/2022)
NC Office of Vital Records
County (provide city or town if county is unknown)
Ofce Use Only
SFN__________________
Ofce Use Only
SFN__________________
Ofce Use Only
SFN__________________
Please Print
____________________________________________________________________
First Name Middle Name Last Name Last Name prior to rst marriage, if applies
____________________________________________________________________
First Name Middle Name Last Name Last Name prior to rst marriage, if applies
_________________________________________________________________________
First Name Middle Name Last Name Last Name prior to rst marriage, if applies
Marriage Certicate Number of Copies Requested:______ □ Certied (Suitable for legal purposes) ______ □ Uncertied (Not suitable for legal purposes)
Divorce Certicate Number of Copies Requested:______ □ Certied (Suitable for legal purposes) ______ □ Uncertied (Not suitable for legal purposes)
Death Certicate Number of Copies Requested:______ □ Certied (Suitable for legal purposes) ______ □ Uncertied (Not suitable for legal purposes)
How do you plan to use this record?
___________________________________________________________
Signature of Person Requesting the Certicate
___________________________________________________________
Print Name of Person Requesting the Certicate
___________________________________________________________
Mailing Address Including City, State and Zip Code
(If mailing to a P.O. Box, street address must also be listed to the right)
___________________________________________________________
Street Address Including City, State and Zip Code
___________________________________________________________
Date Signed
___________________________________________________________
(Area Code) Telephone Number (During business hours)
Ofce Use Only: SFN _______________________________ DCN _____________________________ Cartridge/Frame __________________________________
Amount received: $_______________________ Identication presented_________________________________________________________________________
Request number ___________________________________________Request date ________________________________________________________________
I hereby certify that all the above information is true to the best of my knowledge. Note: It is a felony violation of North Carolina Law (G.S. 130A-26A) to make a false statement on this
application or to unlawfully obtain a copy or certied copy of a vital record.
Identication of the person requesting a certicate is required. See page 2 for a list of acceptable IDs.
Order Certi icate
A certificate search costs $24 and includes one copy if the certificate is located. The search covers a three-
year period. Requests are processed in the order received and can take up to five weeks plus the mail delivery
time. The search fee is required to process a request and is non-refundable even if a record cannot be located.
Identication Requirement
Due to identity theft and other fraudulent use of vital records, ID of the person requesting a certicate is
REQUIRED. Requests that do not include ID will be returned. You MUST include a legible photocopy of
one of the photo IDs listed below with your request:
• Current state-issued driver’s license (address must match requestor’s address on application)
• Current state-issued non-driver photo ID card (address must match requestor’s address on application)
• Current Passport or Visa (must include photo)
• Current U.S. military ID
• Current Department of Corrections photo ID card dated within the last year
• Current state or U.S. government agency photo ID card (for persons requesting certicates as part of that
agency’s business)
• Current student ID card with copy of transcript
If you do not have one of the IDs listed above, you must provide legible photocopies of TWO of the following
(must be two DIFFERENT forms of ID):
• Temporary driver’s license
• Current utility bill with current address
• Car registration or title with current address
• Bank statement with current address
• Pay stub with current address
• Income tax return/W-2 form showing current address
• Letter from government agency dated within the last six months and showing current address
• State-issued concealed weapon permit showing current address
If you are unable to meet our ID requirements, a family member or other person
who is entitled to obtain the certicate, and who can meet the ID requirements, may request it.
A list of persons entitled to obtain certificates is located on our website at
https://vitalrecords.nc.gov/faqs.htm.
DHHS-VR-DMD (Revised 01/2022)
NC Office of Vital Records
For current processing times for expedited requests, see our website at https://vitalrecords.nc.gov/processing-
dates.htm.
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Application for North Carolina Death, Marriage or Divorce (North Carolina)

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Completed 10 January 2022

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