COMMONWEALTH OF KENTUCKY
STATE REGISTRAR OF VITAL STATISTICS
APPLICATION FOR A CERTIFIED COPY OF DEATH CERTIFICATE
Certificates of Death that occurred in Kentucky since 1911 are on file in this office
Please Print or Type Sections 1 through 12
DEATH CERTIFICATE INFORMATION
Name of Hospital (if any)
4. Attending Physicians
Name
5. Funeral Service
Provider
6. What is your relationship to the person whose certificate is being requested?
7. Requestor’s Printed Name
8. Requestor’s Phone Number
Phone number with area code
9. Requestor’s Mailing Address
10. Requestor’s City, State, Zip
11. Requestor’s Signature
Certificates may also be ordered by the following methods:
Internet: Certificates may be ordered on the internet using a credit card (Visa, MasterCard, Discover or American Express) or check. An additional charge
card fee will apply. This is in addition to the fee for each certified copy requested. Certificates requested via internet, https://www.vitalchek.com/death-
certificates/kentucky, may be delivered by overnight courier with payment of the additional shipment fee if that record is available.
Telephone: Orders may be placed by telephone using a credit card (Visa, MasterCard, Discover or American Express) or check. An additional charge card
fee will apply. This is in addition to the fee for each certified copy requested. Certificates requested via telephone may be delivered by overnight courier
with payment of the additional shipment fee. The telephone number to place your order is (800) 241-8322, choose option 1.
Mail: Orders are accepted by mail, using a check or money order in U.S. dollars drawn on a U.S. bank for payment. It can take up to 30 working days to
process your request from the date payment is posted. Mail to Vital Statistics, 275 East Main Street 1E-A, Frankfort, KY 40621. The Office of Vital
Statistics telephone number is (502) 564-4212.
Drop Box: The Office of Vital Statistics installed a drop box at the visitor entrance at 275 E. Main St., Frankfort for applications for certified copies of birth,
death, marriage and divorce certificates. Blank applications are provided on the drop box.
Currently all in-person services for the Office of Vital Statistics are suspended until further notice.
DO NOT WRITE IN THIS SPACE
12. FEES – NON REFUNDABLE
A fee is to be paid for certified copies or records or for a search of the files or records when no
record is available. The fee for a certified copy of a death certificate is $6.00 U.S. Additional
copies are $6.00 U.S. each. Make check or money order payable to “Kentucky State
Treasurer.” This fee is non refundable.
________ Certified Copies @ $6.00 each = $
How many Total payment
