Fillable Correcting a Death Certificate (Texas Real Estate Contracts)

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Correcting a Death Certificate (Texas Real Estate Contracts)

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The Correcting a Death Certificate (Texas Real Estate Contracts) form is 4 pages long and contains:

  • 2 signatures
  • 27 check-boxes
  • 68 other fields

Country of origin: US
File type: PDF

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The Texas Real Estate Commission (TREC) is an agency that governs real estate practices in the state of Texas USA. I its headquarters are located in Ausin Texas at 1700 North Congress.

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Texas
Department
.
of
State
Health
Services
Correcting a Death Certificate
Who Can Apply for a Correction?
• The funeral director named on the death certificate.
• The Informant named on the death certificate.
• The surviving spouse or surviving parent named on the death certificate.
• Medical certifier, if a fetal death certificate.
How Do I Make a Correction?
☐ Complete and sign this application. See pages 3 and 4.
☐ Section 1 through 4 MUST be completed. See page 2 for instructions.
☐ Everyone
signing section 5 must sign before a notary public and ATTACH A
COPY OF THEIR VALID PHOTO ID(S)
.
☐ The application must be original. P
hotocopies, alterations, strike-through, or write overs will not
be
accepted.
☐ Submit
the appropriate documentation. See page
2.
☐ Submit the appropriate
fees. See fee schedule
below.
For Frequently Asked Questions, go to: https://www.dshs.texas.gov/vs/faq/#correct.
For more information, go to: https://www.dshs.texas.gov/vs/requirements.aspx.
Where Do I Mail the Application?
Regular Mailing Instructions - Estimated processing time is 6-8 weeks.
See https://www.dshs.texas.gov/vs/processing/ for current times.
Please submit your application, supporting documents (if required) and fees to:
DSHS – Vital Statistics Section, P.O. Box 12040, Austin, TX 78711-2040.
Expedited Service Mailing Instructions - Estimated processing time is 20-25 business days.
The order and $5.00 processing fee must be sent to the Vital Statistics Section via an overnight mail
service such as: FedEx, Lone Star, or UPS.
Please submit your application, supporting documents (if required) and fees to:
DSHS-Vital Statistics Section, MC 2096, 1100 W. 49
th
Street, Austin, TX 78756.
FAILURE TO PROVIDE INFORMATION REQUESTED ON THIS FORM, MAY RESULT IN SIGNIFICANT
PROCESSING DELAYS AND/OR DENIAL OF YOUR APPLICATION.
Fees: How much must I submit?
Fee Schedule
Fee
($)
Qty
(#)
Total
($)
Filing Fees:
☒
Correction to Death Certificate
$15.00
=
$15.00
For urgent requests, orders may be EXPEDITED by paying the below expedited processing fee
AND sending the order through an overnight mail service, such as: FEDEX, LoneStar, or UPS
to: DSHS-Vital Statistics Section, MC 2096, 1100 W. 49
th
Street, Austin, TX 78756.
☐
Expedited processing Fee (per application)
$5.00
=
All orders are returned free of charge by USPS regular mail. For expedited return mail
service, select one of the overnight return shipping methods below.
☐
Expedite Overnight Mail (shipping within USA)
$8.00
=
☐
USPS Express Overnight Mail (shipping overnight to PO Box ONLY)
$22.95
=
Death Certificate(s):
☐
Certified Corrected Death Certificate – 1
st
Copy
$20.00
1
=
☐
Certified Corrected Death Certificate – Additional Copy(s)
$3.00
Grand Total
Fees may be combined in one check or money order made payable to DSHS – Vital Statistics
For the status of your request, contact VSS by telephone at 1-888-963-7111 or online at: https://www.dshs.texas.gov/orderstatus/.
Page 1 of 4 VS-172 (Rev. 1/21)
What type of correction are you requesting?
A correction to a death record may be filed to complete or correct a record that is incomplete or proved by satisfactory
evidence to be inaccurate. The amendment shall be attached to and become a part of the legal record of the death.
You must complete pages 3 and 4 of this application and may need to provide a supporting document (See Box#1)
.
Box # 1: Document Checklist
I want to…
You will need one of the supporting documents
shown in Box # 2 below
Applicant
should be:
Correct decedent’s name
No documentation required if applicant is the Informant
or Funeral Director. If not, 1,2,4,5,6,7, or 8.
Informant,
Funeral Director,
Surviving Spouse
or Surviving
Parent
Add one “also-known-as” or AKA
to the deceased’s name that is a
similar name
No documentation required if applicant is the Informant
or Funeral Director. If not, 9
Correct date of birth and/or age
of decedent
No documentation required if applicant is the Informant
or Funeral Director; otherwise, 2, 5 or 9.
Correct decedent’s sex
No documentation required if applicant is the Informant
or Funeral Director; otherwise, 5 or 9.
Correct birthplace of decedent
No documentation required if applicant is the Informant
or Funeral Director; otherwise, 2, 4, 5 or 9.
Correct social security number of
decedent
No documentation required if applicant is the Informant
or Funeral Director; otherwise, 3.
Correct decedent’s parent’s first,
middle or last name
No documentation required if applicant is the Informant
or Funeral Director; otherwise, 2, 5 or 9.
Correct marital status of
decedent
No documentation required if applicant is the Informant;
otherwise, 9. If changing status to married, must add
name of surviving spouse.
Informant
Correct surviving spouse’s name
No documentation required to correct misspellings, if
applicant is the Informant or Funeral Director; otherwise,
9. If correction is more significant than the spelling, 9.
Informant or
Funeral Director
Correct informant’s information
Correct decedent’s residence
street address
No documentation required.
Correct method or place of
disposition
No documentation required.
Funeral Director
Correct Name and Address of
Funeral Facility
For Funeral Home replacement, provide a letter from the
Funeral Home on the death certificate; otherwise, 9.
Correct place of death
7 or 8
Correct Medical Information
(Date of death and information
at or below “Certified” line –
items 26-41)
10
Medical Certifier
Correct Medical Information –
Fetal death certificate
No documentation required.
Suggested Supporting Documents:
Documents must be original certified copies (no photocopies), on official letterhead, or with an original
certification or seal unless otherwise specified below. Foreign documents, including notaries must have an apostille or
legalization, from the Foreign Country where the document was issued. All supporting documents must match the
requested correction(s) exactly.
Box # 2: Supporting Documents
1
Funeral home contract or worksheet – Photocopy accepted
2
Baptismal certificate - Must be within first 5 years of birth
3
Social security card of deceased – Photocopy accepted
4
Armed forces discharge papers (form DD 214) – Photocopy accepted
5
Birth certificate of deceased
6
Divorce record (limited use)
7
Medical records
8
Medical Examiner/Justice of the Peace, Police or EMS Reports
9
A certified copy of a court order affecting information shown on the death certificate. Include all pages with
judge’s signature and seal of the court.
10
Medical amendment filed by the medical certifier
Page 2 of 4 VS-172 (Rev. 1/21)
TEXAS
Health
a1
nd
Human
Services
Texas
Department
of
State
Health
Services
IMPORTANT: Photocopies, alterations, strike-through, or
write overs in Section 1 through 5 will not be accepted.
Please use a new application if you make a mistake.
Death Certificate Correction Application
Remittance No.____________
Type or Print (please use blue or black ink ONLY)
Section 1: What is Your Name? (Applicant’s Information)
Name (First, Middle, Last):
Address (Mailing Address, City, State, Zip):
Email Address:
Telephone # (daytime)
( ) -
Your relationship to Person named on the death certificate:
☐Funeral Director ☐Informant ☐Surviving Spouse/Parent ☐Medical Certifier (Fetal Death Only)
>>>>>>>A COPY OF THE APPLICANT’S PHOTO ID MUST BE ATTACHED<<<<<<<
Section 2: Death Certificate Information
Enter information as it appears on the current death certificate (before corrections).
Death Certificate Number, if known:
142 - -
Decedent’s First Name:
Middle Name:
Last Name:
Date of Death:
Sex:
Place of Death (City or town)
(County)
(State)
TEXAS
Decedent’s Date of Birth:
Decedent’s Social Security Number, if known:
Section 3: What do you want to correct?
We cannot accept whiteout, strike-through, alterations, or write overs.
List items to be added,
corrected or removed
What is on the death certificate
now?
What should the death
certificate say?
Example: Decedent’s First Name
Andre
Andres
Example: Date of Birth
August 2, 1955
August 12, 1956
Page 3 of 4 VS-172 (Rev. 1/21)
•
•
I
I
I
Section 4: Would you like to request a death certificate?
Check one:
No, I would not like a certified copy of the corrected death certificate.
Yes, I would like a certified copy of the corrected death certificate. Number requested: ______
Please verify fees and quantity ordered in the fee box on Page 1.
Section 5: Affidavit
Please sign below in the presence of a notary public and ATTACH a copy of your valid Photo ID.
Applications without acceptable valid ID attached will not be processed.
Cross-outs or white-outs will VOID
your application.
WARNING: The Penalty for knowingly making a false statement in this form can be 2-10 years in prison
and a fine of up to $10,000. (Texas Health and Safety Code, Chapter 195).
Applicant
>>>>>ATTACH A COPY OF YOUR VALID PHOTO ID<<<<<
Printed Name:
Signature:
Address:
City:
State:
Zip:
Notary Public, County Clerk, or other person authorized to administer oaths
Sworn to and subscribed before me, this ______ day of ____________ 20______.
[Stamp or Seal]
Signature:
Printed name and title:
Page 4 of 4 VS-172 (Rev. 1/21)
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Correcting a Death Certificate (Texas Real Estate Contracts)

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Completed 15 March 2021

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