Fillable Cincinnati Office of Vital Records and Statistics Application (City of Cincinnati)

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Cincinnati Office of Vital Records and Statistics Application (City of Cincinnati)

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The Cincinnati Office of Vital Records and Statistics Application (City of Cincinnati) form is 1 page long and contains:

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15 other fields

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File type: PDF

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BROWSE CITY OF CINCINNATI (OH) FORMS

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Cincinnati Office of Vital Records and Statistics

Application for Certified Copies of Death Certificate

Applications without proper identification & documentation of relationship to deceased will not be processed.

This form is for mail in orders only

Certificate Information: (Information about the person on the requested certificate)

Death certificate - $27.00 Each Copy – Number of copies______ Stillbirth certificate - $27.00 Each Copy – Number of copies____

Certificado de defunción - $ 27.00 Cada copia - Número de copias Certificado de muerte fetal - $ 27.00 Cada copia - Número de copias

No documentation required*

What relationship are you to the deceased? Please check below

Decedent’s Spouse

County Veterans Service Officer

Lineal descendant

Private Investigator

Media

Federal/ State government agency

Executor of estate/administrator

Power of Attorney

Funeral Director or Employee/ Agent

Adult Representative from written Declaration

Please attach copies of documentation of relationship to deceased & Identification

(See attached listing for acceptable documentation)

Applicant Information: (Information about the person requesting the certificate)

Información del solicitante: (Datos de la persona que solicita el certificado)

NO PERSONAL CHECKS ARE ACCEPTED-UNLESS CERTIFIED

A Non-Refundable Research Fee Charge For Each Certificate Not Found $3.00

Mail in orders (allow up to 1 week) Money orders should be made payable to “Treasurer, City of Cincinnati”

Applying by mail please send the completed application, self-addressed stamped envelope, and the correct fee $27.00 to:

Office of Vital Records and Statistics This space for office use only

1525 Elm Street

Cincinnati, Ohio

45202-6995

513-352-3120

For on-line ordering or additional information, visit our website

http://www.cincinnati-oh.gov/health/birth-death-certificates/

Name of Deceased

(Nombre)

Middle Name

(Segundo Nombre)

Last Name

(Apellido)

Date of Death

Month (Mes) Day(Dia) Year (Ano)

What is the reason for request?

Place of Death

Lugar de la

muerte

City

CINCINNATI

County

HAMILTON

State

OHIO

Hospital or Address of Death

(Hospital o en la direcci`on)

Applicant Name \ Funeral Home Name

(Nombre del solicitante \ Nombre de funeraria)

Email:

Street Address:

(Dirección) City (Ciudad) State (Estado) Zip (Código postal )

Phone Number:

(Número de teléfono)

Your Signature

(Su firma)

Date

(Fecha)

Pursuant to Ohio Revised Code 3705.29, it is unlawful to purposely obtain, possess, use, sell, furnish, or attempt to obtain, possess, use, sell or furnish to

another for the purpose of deception any certificate, record or certified copy of it that relates to the birth of another person, whether living or dead.

Certificate No.

Documents verified Initial

Paper No.

Initial

Please attach copy of Photo ID

Print Form

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

Forthefirstfiveyearsafteradecedent’sdeath,adecedent’ssocialsecuritynumbershallnotbeincludedonacertified

copyofthedecedent’sdeathcertificateunlessthatinformationisspecificallyrequeste dtobeonthecertifiedcopyby

oneofthefollowingwhopresentsproofsatisfactorytothe

localregistraroftheperson’sidentity.PleaseseeORC

3705.23

Pleaseseethefollowinglistwithacceptableidentificationandproof.Ifthelocalregistrarcriteriaarenotmeetadeath

certificatewillbeissuedwithoutthesocialsecuritynumber.

Person(s)onlisttoreceivefull

DeathCertificate

IdentificationProvided Verificationof

Relationship

Decedent’sSpouse

PrimaryIdentification

 ValidgovernmentissuedphotoID

 PhotoWorkID

 SchoolPhotoID

 GunPermit

 ForeignPassport

 GreenMexicoConsularID

 Re‐entrypermit(currentI‐327)

 Refugetraveldocuments(currentI‐

571)

 Temporaryresidentcard(currentI‐688)

SecondaryIdentification(2

needed)

 VoterRegistrationCard

 VehicleRegistration

 SignedSocialSecuritycard

 HuntingLicense

 UtilityBill

 InsuranceCard

 DeathCertificate

 MarriageLicense



CountyVeteransServiceOfficer

PrimaryIdentification

 ValidgovernmentworkphotoID

Veteransformcompleted

Alinealdescendant(bloodrelativein

thedirectlineofdescent)

PrimaryIdentification

 ValidgovernmentissuedphotoID

 Passport

 PhotoWorkID

 SchoolPhotoID

 GunPermit

 GreenMexicoConsularID

SecondaryIdentification(2needed)

 VoterRegistrationCard

 VehicleRegistration

 SignedSocialSecuritycard

 HuntingLicense

 UtilityBill

 InsuranceCard



 BirthCertificates

 BaptismalCards

PrivateInvestigator

PrimaryIdentification

 ValidgovernmentissuedphotoID

 WorkID

 GunPermit

PrivateInvestigator

licenseClassAorClassB

Person(s)onlisttoreceivefullDeath IdentificationProvided Verificationof



Certificate Relationship

Federal/State/Localgovernment

agencychargedwith

detecting/prosecutingcrime

PrimaryIdentification

 ValidgovernmentworkphotoID

Verificationon

employersletterhead

statingthecasewiththe

nameddecedent

requestingacertified

copywithmanagers

nameandsignature

Media

PrimaryIdentification

 ValidgovernmentissuedphotoID

 Passport

 WorkID

 GunPermit



LetteronEmployers

letterheadstatingperson

workingonstoryrelated

todecedentwith

managersnameand

signature

Executorofestate/administrator

PrimaryIdentification

 ValidgovernmentissuedphotoID

 Passport

 PhotoWorkID

 SchoolPhotoID

 GunPermit

 GreenMexicoConsularID

SecondaryIdentification(2needed)

 VoterRegistrationCard

 VehicleRegistration

 SignedSocialSecuritycard

 HuntingLicense

 UtilityBill

 InsuranceCard



Certifiedcourt

documentationfor

permissionasexecutor

PowerofAttorney

PrimaryIdentification

 ValidgovernmentissuedphotoID

 Passport

 PhotoWorkID

 SchoolPhotoID

 GunPermit

Certifiedcourt

documentation

AdultRepresentative

PrimaryIdentification

 ValidgovernmentissuedphotoID

 Passport

 PhotoWorkID

 SchoolPhotoID

 GunPermit

Certifiedcourt

documentation

FuneralDirectororEmployee

PrimaryIdentification

 DeathCertificateforfiling

 FuneralhomeIdentification

 DeathCertificate

forfiling

ValidgovernmentissuedphotoID(driver’slicense,stateID,driver’spermit,DepartmentofCorrectionsID,military

ID



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Completed 2 August 2020

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