Fillable Death Appl2017 Wisconsin Death Certificate Application (City of Milwaukee)

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Death Appl2017 Wisconsin Death Certificate Application (City of Milwaukee)

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DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-05280 (Rev. 11/2016)
STATE OF WISCONSIN
Wis. Stat. § 69.21
Page 1 of 2
WISCONSIN DEATH CERTIFICATE APPLICATION
(for Mail or In-Person Requests)
PENALTIES: Any person who illegally possesses any vital record with knowledge that the vital record has been illegally obtained is guilty of a Class I felony [a fine of not more than
$10,000 or imprisonment of not more than 3 years and 6 months, or both, per Wis. Stat. § 69.24(1)].
I. APPLICANT INFORMATION
CURRENT NAME - First
Last
MAIL TO NAME - First (if different)
Last
MAIL TO ADDRESS (if different than street address) Apt. No.
City
State
ZIP Code
City
State
ZIP Code
EMAIL ADDRESS
TYPE OF CURRENT VALID PHOTO ID
(See item 4, on page 2.)
PHOTO ID NUMBER
STATE OF ISSUANCE
EXPIRATION DATE
II. APPLICANT’S RELATIONSHIP TO
PERSON NAMED ON THE CERTIFICATE
Per Wis. Stat. § 69.20(1), a CERTIFIED copy of a death certificate is only available to those with a “direct and tangible interest." (A–D)
CHECK ONE box which indicates YOUR RELATIONSHIP to the PERSON NAMED on the death certificate.
A. I am a member of the immediate family of the person named on the death certificate.
Parent (My name is on the death certificate and my parental rights have not been terminated.)
Brother / Sister Current Spouse Child
Maternal Grandparent Paternal Grandparent Current Domestic Partner (registered in the Wis. Vital Records System)
B. I am the legal custodian or guardian of the person named on the death certificate.
C. I am a representative authorized by any person in category A or B, including an attorney.
Specify the person you represent: ____________________________________________________________________________________
D. I can demonstrate the death certificate is necessary for the determination or protection of a personal or property right.
Specify your interest: ______________________________________________________________________________________________
E. I am a direct descendent of the decedent and am requesting an uncertified copy of the death certificate.
F. None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity or legal purposes.)
NOTE: Stepparents, stepchildren, stepbrothers / stepsisters may only obtain certified copies as categories B–D.
PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:
III. FEES
FIRST COPY FEE …………………………………………………………………………………….………………..…… $ 20.00 ___$20.00__
Fact of Death (without cause of death) (sufficient for most financial transactions)
OR Extended Fact of Death (with cause of death) (for insurance benefit claims)
EACH ADDITIONAL COPY (issued at the same time as the first copy)
Fact of Death ………………………………………………..………….….. _____________________ X $ 3.00 ___________
Number of Additional Copies
Extended Fact of Death …………………………………………….……… _____________________ X $ 3.00 ___________
Number of Additional Copies
TOTAL ___________
Submit your application materials and fee to:
Be sure to include: completed form, acceptable identification, payment,
any additional proof or authorization required
IV. DEATH RECORD
INFORMATION
NAME OF DECEDENT - First
Middle
Last
DATE OF DEATH (MM/DD/YYYY)
PLACE OF DEATH - County
PLACE OF DEATH – City, Village, or Township *
DECEDENT’S SOCIAL SECURITY NUMBER *
DECEDENT’S AGE / BIRTHDATE *
DECEDENT’S OCCUPATION *
NAME OF DECEDENT’S SPOUSE *
NAME OF DECEDENT’S PARENT *
NAME OF DECEDENT’S PARENT *
I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies of
the requested death certificate in accordance with the categories listed above.
SIGNATURE (Applicant)
Date Signed (MM/DD/YYYY)
Important: Signature and payment are required for processing.
*The fields marked with an asterisk (*) do not have to be completed. The information is helpful but not required.
TYPE or PRINT.
Clear / Reset Form
FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATION REQUESTS ARE NOT ACCEPTED.
Milwaukee County Register of Deeds, 901 N. 9th St. - Rm. 103, Milwaukee, WI 53233
and a self addressed, stamped, business-size envelope
***Payment must be a money order or cashier's check. No personal checks.***
WISCONSIN DEATH CERTIFICATE APPLICATION
F-05280 (Rev. 11/2016)
Page 2 of 2
1. What is the difference between a “certified” and an “uncertified” copy of a death certificate?
A CERTIFIED COPY:
Is printed on security paper, has a raised seal, and shows the signature of the State Registrar or Local Registrar.
Can be used for legal purposes.
Can only be obtained with a direct and tangible interest as defined in Wis. Stat. § 69.20(1).
AN UNCERTIFIED COPY:
Is printed on plain paper and marked “uncertified.”
Is for information purposes only and cannot be used for identity or legal purposes.
Contains the same information as a certified copy.
2. Limitations on access to cause of death information
Certified and uncertified copies of death records shall not include the extended fact of death (cause of death) unless 50 years have
elapsed from the year in which the death occurred or the requestor has a direct and tangible interest per Wis. Stat. § 69.20(1), or is a
direct descendent of the decedent.
3. How long will it take to process my request?
APPLYING IN PERSON
APPLYING BY MAIL
4. What identification is required when applying for a death certificate?
Requests for certified copies require proof of identification. Applicant’s original ID is required for in-person applications. A photocopy of
the applicant’s ID is required for mail applications.
At least one form of ID must show your name and address. Expired cards or documents will not be accepted.
Examples of acceptable forms of identification include:
One of these:
OR
Two of these:
State issued driver’s license or ID card
US or Foreign passport
Tribal or Military ID card
Bank/Earnings statement
Current, dated, signed lease
Health insurance card
US Government issued photo ID
Utility bill or traffic ticket
Vehicle registration/title
If you have questions regarding this form, please call
or visit our website at
* Requests for certified copies of death certificates are usually completed within 30 minutes of application, if the death
certificate is on file.
* Requests for uncertified copies of death certificates are not completed on the same schedule as requests for certified copies.
In-person requests for uncertified copies will be mailed to applicant and may take up to 2 weeks.
* Requests for certificates may take up to 2 weeks.
* For faster service log on-line at www.vitalchek.com (certified records only). Additional fees applied.
414-278-4027
www.county.milwaukee.gov.
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Death Appl2017 Wisconsin Death Certificate Application (City of Milwaukee)

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Completed 18 July 2020

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