Fillable Date Stamp Here Bureau of Vital Records Request (Arizona Department of Health Services)

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Date Stamp Here Bureau of Vital Records Request (Arizona Department of Health Services)

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VS-159 Page 1 of 2 Revised 1/2021
Bureau of Vital Records Request for Copy of Death Certificate
Attention Applicants: All fields with an asterisk (*) next to the field header are required fields that must be completed.
Info
For Office Use Only – State File Number
Security Paper Number(s)
Order Number
Please visit the Bureau of Vital Records website
https://azdhs.gov/licensing/vital-records/ for the following
information:
• Fees
• Locations, office hours, and availability of services
• Eligibility requirements and acceptable identification
• Correction, amendment, and registration information
• Download forms
Telephone: 602-364-1300
Apply Online: www.VITALCHEK.com
(Refer to website for their
current fees)
CUSTOMER MAIL IN CHECKLIST
Clear photocopy of the front and back of your valid, signed
government photo ID OR have your signature notarized
Proof of relationship enclosed is required (birth certificates,
certified court documents, marriage license, etc)
Sign the application/Original signature required
Include self-addressed stamped envelope
Correct fee enclosed, please do not mail cash-
https://azdhs.gov/licensing/vital-records/index.php#fees-home
Notary is not applicable for gov’t agency requests, please
submit copy of gov’t agency ID badge.
Order Info
Today’s Date
# of Certified
Copies
Requested*
Copies
Requested
Death
Fetal Death
Stillbirth
Purpose of Request*
Payment Method
Enclosed Fee
$
Credit Card
Info
Payment Information: VISA MASTER CARD AMERICAN EXPRESS DISCOVER CARD
__ __ __ __-__ __ __
__-__ __ __ __- __ __ __ __ __ __ / __ __ ______ _____________
Card Number* Card Expiration Date* CVV#* Billing Zip Code*
*If credit card does not
belong to applicant, you
must submit a clear copy
of the credit card holder’s
valid, current government
photo ID with signature.
__________________________________________ __________________________________________
Print Name of Card Holder* Signature of Card Holder*
Amount to be Charged
$
Death Certificate In
fo
Date of Death
Sex
Male Female
Name on Death Certificate*
First Middle Last
Place of Death – Hospital or Residence
Town/City County State
Hospital
Residence
Other: _________________________
Funeral Home or Donation Facility
Date of Birth
Are Copies to be used for U.S. Government Claim?*
Yes No (If yes, indicate type of claim)
Social Security Number
Social Security
Military Allotments
Veterans Pensions
Payments of U.S. government or NSLI life insurance proceeds
Other:
____________________________
Person Requesting
Applicant’s Full Name – Printed*
First Middle Last
Applicant’s Signature*
Signature Date*
Mailing Address*
Street City State Zip
Daytime Telephone Number*
Email Address*
Your Relationship to Person on Certificate–Check One*
*PROOF of relationship MUST be provided. Documentation must be provided to support eligibility.
Parent Relative Grandparent Spouse Gov’t Agency Other: _________________________________________
Notary Area
Applicable only if no government issued photo ID is available
State of _______________________ County of _______________________________
On this _______ day of __________________, 20____ before me personally appeared
_________________________________________ (name of signer), whose identity was
proven to me on the basis of satisfactory evidence to be the person whose name is subscribed
to this document, and who acknowledges that he/she signed the above document.
Notary Signature ____________________________ My Commission Expires: ____________
Office Use Only
ID Verified/Notarized Application
Proof of Eligibility Verified
CC Holder’s ID Verified
Date Issued: _________________
Verification:
Process
Insufficient
Insufficient Reason:
No Fee/Incorrect Fee
Incorrect Payment Type
CC Expired
ID Expired/Invalid
Need Clear Copy of ID
Need CC Holder’s ID w/ Signature
Need ID w/ Signature
Need Signature
Signatures Do Not Match
Applicant Ineligible
Not an AZ Record
Need Documents
Other: _________________________
Date Stamp Here
Affix Seal/Stamp Here
________ ________ ________
____________
___________
PRINT
SAVE AS
EMAIL
RESET
VS-159 Participating Office Locations Page 2 of 2 Revised 3/2021
PARTICIPATING OFFICE LOCATIONS
The State Bureau of Vital Records Office does not provide walk-in service for death certificate issuance. Services available at
the Bureau of Vital Records by appointment only are amendments and corrections for deaths that occurred prior to 2008.
For walk-in customer service, please visit your nearest local county vital records office providing walk-in service as listed below.
Please note payment types accepted at various office locations: Cash (C) - in person only, Money Order/Cashier’s Check (MO),
Personal Check (PC), Credit Cards (CC), Debit Cards (DC).
Please visit https://azdhs.gov/licensing/vital-records/index.php#local-county
or call for the most current fee schedule for each office.
State Bureau of Vital Records
Mail to: PO Box 6018
Phoenix, AZ 85005
(602) 364-1300
(C)-In Person Only (MO) (CC) (DC)
By Appt Only: 1818 W. Adams St.
Phoenix, AZ 85007
Certified Copies of Birth and Death
Certificates are Available by Mail Only
Apache
County Public Health Services District
110 East First Street South
St. Johns, AZ 85936
(928) 337-7668
(MO) (CC) (DC)
Mail to: PO Box 697
St. Johns, AZ 85936
Cochis
e County Health and Social Services
Office of Vital Records
Sierra Vista Office
4115 E. Foothills Dr.
Sierra Vista, AZ 85635
(520) 803-3925 and
(520) 432-9406
(C) (MO) (CC) (DC)
Doug
las Office
1012 North G Ave. Ste.101
Douglas, AZ 85607
(520) 805-5600
(C) (MO) (CC) (DC)
Bis
bee Office
1415 Melody Lane, Building A
Bisbee, AZ 85603
(520) 432-9411
(C) (MO) (CC) (DC)
Bens
on Office
126 W. 5th Street
Benson, AZ 85602
(520) 585-8200
(C) (MO) (CC) (DC)
Wilco
x Office
450 S. Haskell Ave.
Wilcox, AZ 85643
(520) 384-7100
(C) (MO) (CC) (DC)
All sites offer same day service.
Please send any mail requests to the Sierra Vista or
Bisbee locations only.
Coconino County Health and Human Services
2625 N. King St.
Flagstaff, AZ 86004
(928) 679-7272
(C) (MO) (PC) (CC)
Coconino
County Health and Human Services
4402 E. Huntington Dr.
Flagstaff, AZ 86004
(928) 679-7272
(MO) (PC) (CC)
Certified Copies of Death Certificates
are Available by Mail Only
Gila
County Health & Emergency Management
Office of Vital Records
5515 S Apache Ave., Ste.100
Globe, AZ 85501
(928) 402-8811
(C) (PC) (MO) (CC) (DC)
Gra
ham County Health Department
820 W. Main
Safford, AZ 85546
(928) 428-4441
(C) (MO) (PC) (CC) (DC)
Gre
enlee County Health Department
Office of Vital Registration
253 5th St.
Clifton, AZ 85533
(928) 865-2601
(C)(MO)
Mail to: PO Box 936
Clifton, AZ 85533
La Pa
z County Vital Records Office
1112 Joshua Ave, Ste. 206
Parker, AZ 85344
(928) 669-1100
(C) (MO) (PC) (CC) (DC)
Maricopa County
Office of Vital Registration
Central Valley Office
3221 N. 16th St., Ste.100
Phoenix, AZ 85016
(602) 506-6805
(C) (MO) (CC) (DC)
Nort
h Valley Office
2423 W. Dunlap Ave., Ste.110
Phoenix, AZ 85021
(602) 506-6805
(C) (MO) (CC) (DC)
East Valley Office
331 E. Coury Ave.
Mesa, AZ 85210
(602) 506-6805
(C) (MO) (CC) (DC)
Wes
t Valley Office
1850 N 95th Ave., Ste.182
Phoenix, AZ 85037
(602) 506-6805
(C) (MO) (CC) (DC)
For all Mail: PO Box 2111
Phoenix, AZ 85001
Northwest Valley Office
8088 W. Whitney Dr., Ste 2A
Peoria, AZ 85345
(602) 506-6805
(C) (MO) (CC) (DC)
Opening April 2021
Mohav
e County Public Health
County Administration Building Drop Box in lobby
700 W. Beale St.
Kingman, AZ 86401
Mail to: PO Box 7000
Kingman, AZ 86402
(928) 753-0748
(C) (MO) (CC) (DC)
Certified Copies of Birth Certificates are Available by
Mail Only or Drop Box
Nava
jo County Public Health Services District
117 E. Buffalo St.
Holbrook, AZ 86025
(928) 524-4750
(MO) (CC) (DC)
Pima County Health Department
Vital Records Office
3950 S. Country Club Road Ste.100
Tucson, AZ 85714
(520) 724-7932
(C) (MO) (CC) (DC)
Pina
l County Public Health Services District
36235 N. Gantzel Rd.
San Tan Valley, AZ 85140
1-866-960-0633
(C) (MO) (CC) (DC)
Pina
l County Public Health Services District
41600 West Smith-Enke Rd.
Bldg. 15
Maricopa, AZ 85138
1-866-960-0633
(C) (MO) (CC) (DC)
Pina
l County Public Health Services District
Florence - Mail Only
P.O. Box 2945
Florence, AZ 85132
1-866-960-0633
(C) (MO) (CC) (DC)
Pinal
County Public Health Services District
1729 N. Trekell Rd. Ste.120
Casa Grande, AZ 85122
1-866-960-0633
(C) (MO) (CC) (DC)
Santa Cruz County Health Services
2150 N. Congress Dr. Ste.115
Nogales, AZ 85621
(520) 375-7900
(MO) (CC) (DC)
Yav
apai County Health Department
1090 Commerce Dr.
Prescott, AZ 86305
(928) 771-3125
(C) (MO) (PC) (CC/DC)
Certified Copies of Birth Certificates and Death
Certificates are Available by Mail Only
Yuma County Health Services
Vital Records Department
2200 W. 28th St.
Yuma, AZ 85364
(928) 317-4530
(C) (MO) (CC)
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Date Stamp Here Bureau of Vital Records Request (Arizona Department of Health Services)

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Completed 12 May 2021

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