Fillable DIVISION OF PUBLIC AND BEHAVIORAL HEALTH Bureau of (State of Nevada, Department of Information Technology)

Fill Online, Printable, Fillable, Blank DIVISION OF PUBLIC AND BEHAVIORAL HEALTH Bureau of (State of Nevada, Department of Information Technology) Form

Use Fill to complete blank online STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

DIVISION OF PUBLIC AND BEHAVIORAL HEALTH Bureau of (State of Nevada, Department of Information Technology)

On average this form takes 23 minutes to complete

The DIVISION OF PUBLIC AND BEHAVIORAL HEALTH Bureau of (State of Nevada, Department of Information Technology) form is 34 pages long and contains:

  • 0 signatures
  • 8 check-boxes
  • 90 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Nevada, Department of Information Technology

BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Bureau of Health Protection and Preparedness
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242 Fax (775) 684-4156
http://dpbh.nv.gov
AMENDING OR CORRECTING A BIRTH OR DEATH CERTIFICATE
Thank you for submitting your request to amend or correct a birth or death certificate. To amend
or correct a birth or death certificate, the processing time is approximately two (2) to four (4)
weeks upon our office receiving all the required documents and information.
The Office of Vital Records processes all requests in the order received. The Office of Vital
Records does not have an expedited process to ensure fairness to all our customers.
Once our office processes your request, it will be picked in the next business day’s mail. The
amended / corrected certificate will be mailed via standard U.S. mail. You may include a pre-
paid self-addressed stamped envelope to receive the mail quicker upon our processing.
Please remember to read the guide and all instructions closely to avoid your request being
rejected and returned to you.
The correction and the fee of $40.00 will provide the applicant with one (1) certified copy of the
corrected certificate. If the applicant wants additional certified copies of the certificate, please
complete the enclosed “Certificate Application” to request additional certified copies. Please
follow all instructions on this application when requesting additional certificates.
Remember to include the following:
Affidavit for Correction of a Record form OR an original certified court order from a
U.S. District Court
Other verifiable evidence as listed in the “Amendment Chart” OR a Supplemental
Affidavit
Proper payment by check, money order, cashiers check or credit card. If paying by credit
card, an Authorization for Credit Card Use form is included in this packet.
Thank you,
Office of Vital Records
Amending / Correcting a Birth or Death Certificate
Per Nevada Administrative Code 440.023, 440.030 & 440.035
When a Court Order is Required
A court order by a court of competent jurisdiction is required for the following fields, unless a data
entry error can be proven at the time the record was created.
If an error can be proven regarding a name that would normally require a court order
Marital status on a death record
Any name on a birth or death record, except for the following:
o A middle name to a middle initial
o A middle initial to a middle name
o Informant’s name on a death record
o Child’s last name (only) on a birth record when adding a father AND changing the
child’s last name to the father’s last name
Affidavit for Correction of a Record When a Court Order is NOT Required
The rest of this guide is to aid in the process of correcting information on a birth/death certificate
when an affidavit is the appropriate method to amend the certificate. The Affidavit for Correction of
a Record form has been revised and the Supplemental Affidavit form has been created. Both forms
are available on our website at:
http://dpbh.nv.gov/Programs/BirthDeath/dta/Forms/Birth/Death_Vital_Records_-_Forms/
Please note a notation will be placed on the certificate noting an amendment / correction was
processed along with the section(s) amended, unless the court orders a new certificate to be issued.
The requirements and process to correct the information on a birth/death record are as follows:
Who May Apply for Amending the Birth Certificate
The person of record; or
The parent or guardian of the person of record; or
A legal representative of the person of record.
Who May Apply for Amending the Death or Fetal Death Certificate
The funeral director listed on the record; or
The informant listed on the record; or
The certifier listed on the record.
Who May Apply for Amending Medical Information on a Certificate
Pursuant to NAC 440.023 (2), a request to correct medical information on a certificate must
originate with the certifier of the medical information. The certifier listed on the record must sign
(witness) the Affidavit for Correction of a Record form.
Medical information:
Birth certificate: There is no medical information on the birth certificate.
Death or Fetal Death certificate: The date of death, time of death, hospital
(institution), and any section in Cause of Death / Cause.
Documentation Required to Correct a Certificate: (TWO (2) Documents to complete the
process)
Affidavit for Corrections of a Record
This form must be signed (witnessed) by an individual as outlined above on who may can apply.
The “State of Corrections” (item # 8 a and 8b) must be completed concisely and accurately.
-AND-
ONE of the following documents MUST be provided with the Affidavit for Corrections of a Record:
Other Verifiable Evidence
A document that verifies and proves each correction being requested.
A court order from any U.S. District Court is also acceptable as other verifiable evidence.
Any document submitted as other verifiable evidence that is in a language other than English
must be accompanied by a certified translated version of that document. The translation must
be completed by someone authorized to translate documents.
-OR-
Supplemental Affidavit
This form must be completed by an individual that has personal knowledge and can attest to
the correction being requested on the primary affidavit. This personal knowledge is gained
through firsthand experience or observation, through a personal, familial, medical, or a
professional relationship with the person of the record being amended.
This form must clearly and concisely explain how the person signing (witnessing) the form has
knowledge of the information being corrected.
This form must be completed in its entirety by an individual other than the person who signed
(witnessed) the Affidavit for Corrections of a Record.
When Submitting any Affidavit
The document must be notarized.
The document must be completed in its entirety.
The document cannot contain any write overs, cross outs or white outs.
The document must be accurately completed with correct information.
The individual signing (witnessing) this form must be at least 18 years of age.
The document form must be legible.
The document must be typed or completed in blue or black ink.
Fees
Correcting a Record on file with the State Registrar (including one certified copy of the amended
certificate): $40.00
Additional certified copies of a birth/death certificate: $20.00 EACH.
Correcting a Record on file with the State Registrar filed by the certifier and the State Registrar
determines that the correction is not the result of an error by the certifier: $10.00.
How to Submit Documents
In person or by mail:
Division of Public and Behavioral Health
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Bureau of Health Protection and Preparedness
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242 Fax (775) 684-4156
http://dpbh.nv.gov
BIRTH
DEATH
AFFIDAVIT FOR CORRECTION OF A RECORD
State Affidavit No.____________
INFORMATION
AS REPORTED
ON THE
ORIGINALLY
REGISTERED
CERTIFICATE
1a. FIRST NAME
1b. MIDDLE NAME
1c. LAST NAME
2. SEX
4. PLACE OF OCCURRENCE (City or County)
5. NAME OF PARENT / FATHER
6. NAME OF PARENT / MOTHER (LAST NAME PRIOR TO FIRST MARRIAGE (MAIDEN - IF BIRTH RECORD)
STATEMENT
OF
CORRECTIONS
7.
ITEM
NUMBER
8a.
FACTS EXACTLY AS STATED ON THE ORIGINAL RECORD
8b.
FACTS AS THEY SHOULD HAVE BEEN STATED ON THE ORIGINAL AT THE TIME OF OCCURRENCE
WHY ARE
CORRECTIONS
NECESSARY?
9.
I, ___________________________________, currently residing at ___________________________________________________________,
(Print Full Legal Name) (Print Street, City, State, Zip Code)
in relation to the person of record being amended, _____________________, certify and declare under penalty of perjury under the laws of
(Print Relationship)
the State of Nevada, that all assertions of this affidavit are true and accurate to the best of my knowledge.
Witness Signature: ___________________________________________
(Sign in the Presence of a Notary)
_______________________________________________________________________________________________________________________________________________________________________________________________
State of _________________,
County of ________________,
Signed and sworn (or affirmed) before me on this ______day of _____________________, 20________,
by ___________________________________________.
(Name of Person Making the Statement)
The subscribing affiant appeared before me, and proved on the basis of satisfactory evidence, to be the person whose name is within instrument
and affirmed to me. Affiant executed the same in their authorized capacity, and that by the affiant’s signature on the instrument, the person,
or the entity upon behalf of which the person acted, executed the instrument. I certify under penalty of perjury under the laws of the State of
Nevada that the foregoing paragraph is true and correct.
Notary Public: __________________________________ WITNESS my hand and official seal.
My Commission Expires: _________________________
_________________________________________
(Signature of Notary Public)
Reserved for Notary Seal
INSTRUCTIONS (PLEASE READ CAREFULLY)
Who can submit an Affidavit for Correction of a Record?
To correct a BIRTH CERTIFICATE, the witness signing this affidavit must have a relationship with the person of record as the
person whose birth is registered on the certificate, his/her parent, guardian, or a legal representative. Medical information
must be by the certifier.
To correct a DEATH CERTIFICATE, the witness signing this affidavit must have a relationship with the person of record as the
funeral director, certifier or informant listed on the certificate. Medical information must be by the certifier.
What do I need to submit with the Affidavit for Correction of a Record?
Other verifiable evidence (see “Amendment Chart”) proving the facts contained in the principal affidavit OR a
supplemental affidavit (see Guide) executed by a person other than the affiant of this Affidavit for Correction of a Record .
The payment of $40.00 (includes one certified copy of the corrected certificate). Additional certified copies of a birth
certificate or death certificate is $20.00 each. The payment may be made by check, cashier’s check, money order or credit
card. Please make your check, cashier’s check or money order out to the Nevada Office of Vital Records. To pay by credit
card, an Authorization for Credit Cards Use form must be completed and submitted.
PLEASE NOTE: The fee for correcting a birth or death record where the correction is filed by a certifier and the State Registrar
determines that the correction is not the result of an error by the certifier is $10.00.
How do I properly complete the Affidavit for Correction of a Record?
This is a legal document. Please type or print clearly in blue or black ink only. Illegible completion of the form will be
returned. Any white outs, cross outs or write overs will not be accepted. The Affidavit for Correction of a Record must be
fully completed in order to be processed.
Signature of the witness must be notarized. Signatures of a minor will be questioned. The person should be at least 18
years of age to make a correction.
Please complete the section titled “Statement of Corrections” clearly and accurately.
Where do I send the Affidavit for Correction of a Record and supporting documents?
Division of Public and Behavioral Health
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Please allow 2 – 4 weeks to process your request. Any questions regarding correcting a record should be addressed to the Office
of Vital Records at the above address, or by calling our office at 775-684-4242. Please provide the name, full address of where
the certificate should be mailed to and phone number:
..........................................................................................................................................................................................................................................
Name
..........................................................................................................................................................................................................................................
Street Address or P.O. Box
..........................................................................................................................................................................................................................................
City
State
Zip Code
..........................................................................................................................................................................................................................................
Phone Number
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Bureau of Health Protection and Preparedness
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242 Fax (775) 684-4156
http://dpbh.nv.gov
BIRTH
Check One Leave Blank
DEATH
AFFIDAVIT FOR CORRECTIONS OF A RECORD
State Affidavit No.____________
INFORMATION
AS REPORTED
ON THE
ORIGINALLY
REGISTERED
CERTIFICATE
1a. FIRST NAME
List the Person of Record (POR)
1b. MIDDLE NAME
Same as 1 a
1c. LAST NAME
Same as 1a
2. SEX
POR
4. PLACE OF OCCURRENCE (City or County)
List the city and/or county where the birth or death occurred at
5. NAME OF PARENT / FATHER
List a parent of the person of record (Must match record)
6. NAME OF PARENT / MOTHER (LAST NAME PRIOR TO FIRST MARRIAGE (MAIDEN - IF BIRTH RECORD)
List a parent of the person of record (Must match record)
STATEMENT
OF
CORRECTIONS
7.
ITEM
NUMBER
8a.
FACTS EXACTLY AS STATED ON THE ORIGINAL RECORD
8b.
FACTS AS THEY SHOULD HAVE BEEN STATED ON THE ORIGINAL AT THE TIME OF OCCURRENCE
See
List individually the errors on the record
List individually the correct information
Items
List
WHY ARE
CORRECTIONS
NECESSARY?
9. Clearly and concisely explain why the corrections are necessary
I, ________Witness print name here _____, currently residing at _Address where you reside or are located at (Not a P.O. Box)___
(Print Full Legal Name) (Print Street, City, State, Zip Code)
in relation to the person of record being amended, Listed in the instructions, certify and declare under penalty of perjury under the laws of
(Print Relationship)
the State of Nevada, that all assertions of this affidavit are true and accurate to the best of my knowledge.
Witness Signature: _Signature of the person listed here____________
(Sign in the Presence of a Notary)
_______________________________________________________________________________________________________________________________________________________________________________________________
State of _________________, THIS SECTION IS COMPLETED BY THE NOTARY
County of ________________,
Signed and sworn (or affirmed) before me on this ______day of _____________________, 20________,
by ___________________________________________.
(Name of Person Making the Statement)
The subscribing affiant appeared before me, and proved on the basis of satisfactory evidence, to be the person whose name is within instrument
and affirmed to me. Affiant executed the same in their authorized capacity, and that by the affiant’s signature on the instrument, the person,
or the entity upon behalf of which the person acted, executed the instrument. I certify under penalty of perjury under the laws of the State of
Nevada that the foregoing paragraph is true and correct.
Notary Public: __________________________________ WITNESS my hand and official seal.
My Commission Expires: _________________________
_________________________________________
(Signature of Notary Public)
Reserved for Notary Seal
SUPPLEMENTAL AFFIDAVIT (Per NAC 440.030)
PRINT FULL LEGAL NAME: ________________________________________________________________________________
Physical Address: ___________________________________________________________________________________________
City: ________________________________________ State: _________ Zip Code: ______________
E-mail Address: ______________________________________________________ Phone Number: _____________________
I, _____________________________________, certify and declare under penalty of perjury under the laws of the State of Nevada,
(Print Name)
that I have personal knowledge to attest to the information provided in the primary affidavit for ____________________________,
(Person of Record)
and I swear that all the assertions of this affidavit, including my identity, are true and accurate.
My relationship to the person of record is _________________________, and I have this personal knowledge through the
(Relationship)
following course of events: ___________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Signature: ___________________________________________
(Sign in the Presence of a Notary)
State of _________________,
County of ________________,
Signed and sworn (or affirmed) before me on this ______day of _____________________, 20________,
by ___________________________________________.
(Name of person making the statement)
The subscribing affiant appeared before me, and proved on the basis of satisfactory evidence, to be the person whose name is within
instrument and affirmed to me. Affiant executed the same in their authorized capacity, and that by the affiant’s signature on the
instrument, the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under penalty of perjury
under the laws of the State of Nevada that the foregoing paragraph is true and correct.
Notary Public: _________________________________ WITNESS my hand and official seal.
My Commission Expires: _________________________
_________________________________________
(Signature of Notary Public) Reserved for Notary Seal
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Bureau of Health Protection and Preparedness
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242 Fax (775) 684-4156
http://dpbh.nv.gov
SUPPLEMENTAL AFFIDAVIT (Per NAC 440.030)
PRINT FULL LEGAL NAME: _Full legal name of the person attesting to the information _____________________________
Physical Address: _Physical address or location of the person listed above (Not a P.O. Box)___________________________
City: __For the person listed above_________________ State: _________ Zip Code: ____________
E-mail Address: __For the person listed above_____________________________ Phone Number: _____________________
I, ___Same person as listed above______________, certify and declare under penalty of perjury under the laws of the State of Nevada,
(Print Name)
that I have personal knowledge to attest to the information provided in the primary affidavit for Person whose record is being corrected,
(Person of Record)
and I swear that all the assertions of this affidavit, including my identity, are true and accurate.
My relationship to the person of record is _For the person listed above___________, and I have this personal knowledge through the
(Relationship)
following course of events: _Explain in detail HOW you (the person listed above) has personal knowledge of the_______
information being corrected. The personal knowledge must be through firsthand experience. This person cannot be the
same person signing the “Affidavit for Correction of a Record” form. ___________________________________________
Signature: __Signature of the person listed above_________
(Sign in the Presence of a Notary)
State of _________________, THIS SECTION IS COMPLETED BY THE NOTARY
County of ________________,
Signed and sworn (or affirmed) before me on this ______day of _____________________, 20________,
by ___________________________________________.
(Name of person making the statement)
The subscribing affiant appeared before me, and proved on the basis of satisfactory evidence, to be the person whose name is within
instrument and affirmed to me. Affiant executed the same in their authorized capacity, and that by the affiant’s signature on the
instrument, the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under penalty of perjury
under the laws of the State of Nevada that the foregoing paragraph is true and correct.
Notary Public: _________________________________ WITNESS my hand and official seal.
My Commission Expires: _________________________
_________________________________________
(Signature of Notary Public) Reserved for Notary Seal
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
Bureau of Health Protection and Preparedness
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242 Fax (775) 684-4156
http://dpbh.nv.gov
DEATH CERTIFICATE AMENDMENT CHART
(NRS 440.155, NAC 440.023, NAC 440.026, NAC 440.030, NAC 440.035, NAC 440.190)
Other Verifiable Evidence Accepted is a document from an independent source containing information that supports/proves the request to correct the death
certificate.
Funeral home vital/personal information sheet will only be accepted if attached to the record PRIOR to registration.
Supplemental Affidavit must be submitted by an individual, other than the person who executed the Affidavit for Corrections of a Record, with personal knowledge
of the item being amended. This personal knowledge is gained through firsthand experience or observation, through a personal, familial, medical, or a professional
relationship with the person of the record being amended.
Other documentation, not listed below, may be considered as Other Verifiable Evidence; however, ALL documents are subject to approval by the Office of Vital
Records.
Documentation showing cross-outs, white-outs, or alterations of any kind will not be accepted as Other Verifiable Evidence.
1
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Deceased Name
(First, Middle, Last,
Suffix)
Court Order
Certified Court Order
No
Deceased
Listed on
the Death
Certificate
Affidavit for
Correction of a
Record accepted
only when an
error can be
proven
Funeral home vitals/personal information worksheet
signed by the informant and a photo identification of the
decedent
Birth Certificate
No
Date of Death
Affidavit for
Correction of a
Record from the
Certifier
Medical Record or Coroner/Medical Examiner Report
Yes
2
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
County of Death
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
City, Town, or
Location of Death
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
Hospital or Other
Institution-Name
(if not either, give
street)
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
If Hospital, or
Institution indicate
DOA, OP/Emer.
Rm., Inpatient
(Specify)
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
Sex
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Funeral home vitals/personal information worksheet
signed by the informant
Birth Certificate
Letter from a Healthcare professional dated PRIOR to the
date of death
Photo identification issued by Federal/State/County
agency with sex/gender listed
Yes
3
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Race (Specify)
Affidavit for
Correction of a
Record
Funeral home vitals/personal information worksheet
signed by the informant
Medical Record or Coroner/Medical Examiner Report
Yes
Ethnicity
Affidavit for
Correction of a
Record
Funeral home vitals/personal information worksheet
signed by the informant
Medical Record or Coroner/Medical Examiner Report
Yes
Under 1 year
(Mos/Days)
Affidavit for
Correction of a
Record
Birth Certificate
Medical Record or Coroner/Medical Examiner Report
Yes
Under 1 Day
(Hours/Mins)
Affidavit for
Correction of a
Record
Birth Certificate
Medical Record or Coroner/Medical Examiner Report
Yes
Date of Birth
(Mo/Day/Yr)
Affidavit for
Correction of a
Record
Birth Certificate
Certificate of Naturalization
Funeral home vitals/personal information worksheet
signed by the informant
Yes
State of Birth
(If not the US/CA,
name country)
Affidavit for
Correction of a
Record
Birth Certificate
Certificate of Naturalization
Funeral home vitals/personal information worksheet
signed by the informant
Yes
4
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Citizen of What
Country
Affidavit for
Correction of a
Record
Funeral home vitals/personal information worksheet
signed by the informant
Birth Certificate
Certificate of Naturalization
Yes
Education
Affidavit for
Correction of a
Record
Diploma
Transcripts
Funeral home vitals/personal information worksheet
signed by the informant
Yes
Marital Status
(Specify)
Court Order
Certified Court Order
No
Surviving Spouse’s
Name
(Last name prior to
first marriage)
Court Order
Certified Court Order
No
Affidavit for
Correction of a
Record accepted
only when an
error can be
proven
Funeral home vitals/personal information worksheet
signed by the informant and a photo identification of the
decedent
Birth certificate of surviving spouse
Surviving spouse hospital birth records
Surviving spouse’s child’s birth certificate showing the
last name prior to FIRST marriage
No
Social Security
Number
Affidavit for
Correction of a
Record
Social security card/documents
Funeral home vitals/personal information worksheet
signed by the informant
Yes
5
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Usual Occupation
(Give kind of work
done during most
of)
Affidavit for
Correction of a
Record
Personnel documentation from employer
Yes
Kind of Business or
Industry
Affidavit for
Correction of a
Record
Personnel documentation from employer
W-2
Paystub
Yes
Ever in US Armed
Forces
Affidavit for
Correction of a
Record
Military enrollment/discharge documents
Military Identification Card
Yes
Residence:
State
Affidavit for
Correction of a
Record
Utility Bill or Financial Statement supporting residency at
time of death, listing decedent
Yes
County
Affidavit for
Correction of a
Record
Utility Bill or Financial Statement supporting residency at
time of death, listing decedent
Yes
City, Town,
or Location
Affidavit for
Correction of a
Record
Utility Bill or Financial Statement supporting residency at
time of death, listing decedent
Yes
Street and
Number
Affidavit for
Correction of a
Record
Utility Bill or Financial Statement supporting residency at
time of death, listing decedent
Yes
6
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Inside City
Limits
Affidavit for
Correction of a
Record
Utility Bill or Financial Statement supporting residency at
time of death, listing decedent
Yes
Father/Parent
Name
(First, Middle, Last,
Suffix)
Court Order
Certified Court Order
No
Affidavit for
Correction of a
Record accepted
only when an
error can be
proven
Funeral home vitals/personal information worksheet
signed by the informant
Birth certificate of decedent listing the father
No
Mother/Parent
Name
(First, Middle, Last,
Suffix)
Court Order
Certified Court Order
No
Affidavit for
Correction of a
Record accepted
only when an
error can be
proven
Funeral home vitals/personal information worksheet
signed by the informant
Birth certificate of decedent listing the mother
No
Informant
Affidavit for
Correction of a
Record
Funeral home vitals/personal information worksheet
signed by the informant and their photo identification
Yes
7
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Mailing Address
Street
R.F.D No
City or
Town
State
Zip
Affidavit for
Correction of a
Record
Utility Bill
Photo Identification issued by Federal/State/County
agency
Yes
Burial, Cremation,
Removal, Other
(Specify)
Affidavit for
Correction of a
Record
Funeral home vitals/personal information worksheet
signed by the informant
Release/Burial Authorization form
Yes
Cemetery or
Crematory Name
Affidavit for
Correction of a
Record
Funeral home vitals/personal information worksheet
signed by the informant
Release/Burial Authorization form
Yes
Location
City or
Town
State
Affidavit for
Correction of a
Record
Funeral home vitals/personal information worksheet
signed by the informant
Release/Burial Authorization form
Yes
Funeral Director
Signature
(Or Person Acting
as Such)
Affidavit for
Correction of a
Record
Funeral Director License
Yes
Funeral Director
License Number
Affidavit for
Correction of a
Record
Funeral Director License
Yes
8
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Name and Address
of Facility
Affidavit for
Correction of a
Record
Funeral Director License
Yes
Trade Call - Name
and Address
Affidavit for
Correction of a
Record
Funeral home release documents
Yes
Certifier
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
showing attendance at time of death
Yes
Date Affidavit was
Signed
Affidavit for
Correction of a
Record
Date signed MUST match the date the affidavit was
signed
N/A
Hour of Death
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
Name of Attending
Physician if other
than Certifier
Affidavit for
Correction of a
Record
Medical Record showing attendance at time of death
Yes
9
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Pronounced Death
(Mo/Day/Yr)
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
Pronounced Dead
At (Hour)
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
Name and Address
of Certifier
(Physician,
Attending
Physician, Medical
Examiner, or
Coroner)
Affidavit for
Correction of a
Record
Copy of Medical License
Yes
License Number
Affidavit for
Correction of a
Record
Copy of Medical License
Yes
Death Due to
Communicable
Disease
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
Cause of Death
Immediate Cause
(a)
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
10
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Due to, or as
Consequence of
(b-d)
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
Interval between
onset and death
(a-d)
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
Other Significant
Conditions
Affidavit for
Correction of a
Record
Medical Record or Coroner/Medical Examiner Report
Yes
Autopsy
Affidavit for
Correction of a
Record
Autopsy Report
Yes
Was Case Referred
to Coroner
Affidavit for
Correction of a
Record
Coroner/Medical Examiner Report
Sheriff’s Report
Yes
Manner of Death:
Acc, Suicide,
Home, Undet, or
Pending
Investigation
Affidavit for
Correction of a
Record
Coroner/Medical Examiner Report
Sheriff’s Report
Yes
Date of Injury
(Mo/Day/Yr)
Affidavit for
Correction of a
Record
Coroner/Medical Examiner Report
Sheriff’s Report
Yes
11
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
Hour of Injury
Affidavit for
Correction of a
Record
Coroner/Medical Examiner Report
Sheriff’s Report
Yes
Describe How
Injury Occurred
Affidavit for
Correction of a
Record
Coroner/Medical Examiner Report
Sheriff’s Report
Yes
Describe How
Injury Occurred
Affidavit for
Correction of a
Record
Coroner/Medical Examiner Report
Sheriff’s Report
Yes
Injury at Work
(Specify)
Affidavit for
Correction of a
Record
Coroner/Medical Examiner Report
Sheriff’s Report
Yes
Place of Injury
(At home, farm,
street, factory,
office building,
etc.)
Affidavit for
Correction of a
Record
Coroner/Medical Examiner Report
Sheriff’s Report
Yes
Location
Street
R.F.D No
City or
Town
State
Affidavit for
Correction of a
Record
Coroner/Medical Examiner Report
Sheriff’s Report
Yes
12
Field on Death
Certificate
Affidavit
Or
Court Order
Other Verifiable Evidence Accepted
Supplemental
Affidavit
Accepted?
AKA
(Also Known As)
Affidavit for
Correction of a
Record
Photo Identification issued by Federal/State/County
Agency
Yes
Division of Public and Behavioral Health
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
(Rev 07/16/2018) (775) 684-4242
Death Certificate Item Numbers
For Affidavit for Corrections of a Record Form
1a.
Deceased Name
20a.
Funeral Director
2.
Date of Death
20b.
Funeral Director License Number
3a.
County of Death
20c.
Name and Address of Facility (Funeral
Director)
3b.
City, Town or Location of Death
21a.
Certifying Physician or Advanced Practice
Registered Nurse
3c.
Hospital or Other Institution
21b.
Date Signed
3e.
If Hospital or Other Institution Indicate
21c.
Hour of Death
4.
Sex
21d.
Name of Attending Physician if Other Than
Certifier
5.
Race
22a.
Certifying Coroner or Medical Examiner
6.
Hispanic Origin?
22b.
Date Signed
7a.
Age
22c.
Hour of Death
7b.
Under 1 year
22d.
Pronounced Dead Date
7c.
Under 1 day
22e.
Pronounced Dead Time
8.
Date of Birth
23a.
Name and Address of Certifier
9a.
State of Birth
23b.
License Number (Certifier)
9b.
Citizen of What Country
24a.
Registrar Signature
10.
Education
24b.
Date Received by Registrar
11.
Marital Status
24c.
Death Due to Communicable Disease
12.
Surviving Spouse
25a.
Immediate Cause
13.
Social Security Number
25b.
Due To, Or As a Consequence Of
14a.
Usual Occupation
25c.
Due To, Or As a Consequence Of
14b.
Kind of Business or Industry
25d.
Due To, Or As a Consequence Of
Ever in US Armed Forces
Part II
Other Significant Conditions
15a.
Residence – State
26.
Autopsy
15b.
County
27.
Was Case Referred to Coroner
15c.
City, Town or Location
28a.
Manner of Death (Accident, Suicide,
Homicide, Natural, Natural with Injury,
Undetermined or Pending Investigation)
15d.
Street and Number
28b.
Date of Injury
15e.
Inside City Limits
28c.
Hour of Injury
16.
Father / Parent Name
28d.
Describe How Injury Occurred
17.
Mother / Parent Name
28e.
Injury at Work
18a.
Informant – Name
28f.
Place of Injury
18b
Mailing Address (Informant)
28g.
Location (Street, City or Town & State)
19a.
Burial, Cremation, Removal or Other
19b.
Cemetery or Crematory – Name
19c.
Location City or Town & State (Cemetery or
Crematory)
State of Nevada
Division of Public and Behavioral Health
Bureau of Preparedness, Assurance, Inspections and Statistics
Office of Vital Records and Statistics
4150 Technology Way, Suite 104
Carson City, Nevada 89706
Telephone (775) 684-4242
http://dpbh.nv.gov
APPLICATION FOR A CERTIFIED DEATH CERTIFICATE COPY OR VERIFICATION
A COPY OF THE APPLICANT’S PHOTO IDENTIFICATION AND FULL PAYMENT IS REQUIRED FOR ALL
REQUESTS. PROOF OF RELATIONSHIP IS REQUIRED FOR CERTIFICATE REQUESTS. Make payment payable to:
Office of Vital Records. Checks, money orders and credit cards are accepted. Please include an Authorization for Credit Card Use
form if paying by credit card.
Name of the Person on the Certificate:
First
Middle
Last
Date of Death
County of Death
Social Security Number
Parent’s First and Last Name
Parent’s First and Last Name
Last Name(s) Prior to First Marriage
Funeral Home / Mortuary in Charge of Arrangements
NRS 440.650 and NAC 440.070 requires the applicant to establish a direct relationship by blood or marriage, a
legal relationship or a need to facilitate a legal process to receive a certified copy of a record. Below, indicate
your relationship or your legal need for this certificate. Please provide proof such as a birth certificate or court
order, unless the applicant is the informant, listed surviving spouse or a parent listed on the certificate. The
request will be rejected if sufficient proof is not provided. Visit our website listed above for more information
regarding proof required.
Relationship and Reason for Request
Applicant’s Printed Name
Applicant’s Signature
Applicant’s Address
Applicant’s Phone Number
FOR OFFICE USE ONLY
Receipt number: _________________________ Date: ______________________
(Rev.02/15/2017)
Number of Copies
FEE FOR A CERTIFIED DEATH CERTIFICATE COPY
$20.00 per certificate
X
TYPE OF CERTIFICATE (Please check one type box below)
Certificate(s) to read as “Mother / Father”
Certificate(s) to read as “Parent / Parent”
X
VERIFICATION ONLY
Verifies the existence of a record with the State of Nevada and does not include a certified copy.
Search/Verification - $10.00 per search / verification
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

DIVISION OF PUBLIC AND BEHAVIORAL HEALTH Bureau of (State of Nevada, Department of Information Technology)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document