DEATH CERTIFICATE APPLICATION
Death Certificate Fees
(per request)
Purchase of First
Certificate $38.00
Each Additional Copy
$25.00
Number of Copies_____________
Is this a fetal death certificate?
$10 Search/Verification- search/verifications do not include a certified copy.
Full Name of Deceased: _____________________________________________________________________________________
Date of Death: _____________________________________Date of Birth of the Deceased: _____________________________
Name of Father of Deceased: _________________________________________________________________________________
Name of Mother of Deceased: ________________________________________________________________________________
Mortuary:__________________________________________________________________________________________________
Your N
ame:_______________________________________________________________________________________________
Your Address:______________________________________________________________________________________________
City: ____________________________ State: _________________________ Zip Code:__________
Email:________________________________________ Phone Number:________________________________
By signing this document I declare under penalty of perjury under the laws of the state of Nevada, that I am an
authorized person, as defined in Nevada Revised Statute 440.650 and Nevada Administrative Code 440.070, and am
eligible to receive a certified copy of the death certificate of the above named individual.
Signature of Applicant: _______________________________________________ Date:________________________
NRS 440.650 and NAC 440.070 require that a relationship or a need to facilitate a legal process be established in order to receive a certified
copy of a record.
To receive a Certified Copy I am:
A parent, child, grandparent, grandchild, brother or sister, spouse, or registered domestic partner of the
deceased. Specify:__________________________________
A party entitled to receive the record as a result of a court order or an attorney seeking the death record in
order to comply with the legal requirements.
An attorney representing the deceased or the deceased’s estate, or any person or agency empowered by
statute or appointed by a court to act on behalf of the deceased or the deceased’s estate.
A person with appointed rights in a power of attorney, or an executor of the deceased’s estate. (Please include
a copy of the power of attorney, or supporting documentation identifying you as executor.)
A member of a law enforcement agency or a representative of another governmental agency, as provided by
law, who is conducting official business. (Companies representing a government agency must provide
authorization from the government agency.)
Other:___________________________________
Note: Nevada law states that the possession, sale and transfer of identity information is punishable by law.
NRS
Mail to: Southern Nevada Health District – Vital Records Office
Attn: Vital Records
PO Box 3902 | Las Vegas, NV 89127
(702) 759-1010 Fax (702) 759-1421 | http://www.SNHD.info
