Fillable Death Certificate Application (City of Borger, Texas)

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Death Certificate Application (City of Borger, Texas)

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The Death Certificate Application (City of Borger, Texas) form is 2 pages long and contains:

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  • 17 check-boxes
  • 53 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Borger, Texas

BROWSE CITY OF BORGER, TEXAS (TX) FORMS

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Parent 1: First, Middle, Last name prior to first marriage (Maiden Name) Please separate with a space between first, middle and last name.
Place of Death
Step 2 : INFORMATION FOR THE PERSON NAMED ON DEATH CERTIFICATE (PLEASE PRINT)
Reason for Request: Records Estate Insurance
Other: ____________________________
Step 3 : COST & FEES (FEES NON-REFUNDABLE)
Date of Death Date of Birth
Social Security Number
Month
Month
Day
Day
Year
Year
City
County State
Select Certicate Type:
First Death Certicate
Additional Death Certificate(s)
Qty Price/each Total
Total Due
x $20.00
x $20.00
$
$
$
$
x $3.00
COUNTY OF _________________________________
This instrument was acknowledged before me on ___________________________
by _________________________________________________________________
__________________________________
(Date)
(Name of person acknowledging)
(Notary Public’s Signature)
(Personalized Seal)
Death Verication
TEXAS DEATH CERTIFICATE APPLICATION
PLEASE PRINT. APPLICATION MUST BE ORIGINAL (INCLUDING SIGNATURE). NO CROSS OUT OR WHITE
OUT WILL BE ACCEPTED. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Step 1: YOUR INFORMATION AND SHIPPING ADDRESS (PLEASE PRINT)
Your Name (First, Middle, Last Name, Suffix) Please separate with a space between first, middle and last name.
Street Address
City
State
Zip Code
E-mail Address Daytime Phone Number
First, Middle and Last Name, Suffix (Please separate with a space between first, middle and last name.
Address to Send Certicate to if dierent than noted above
City
State
Zip Code
Your relationship to Person named
on Certificate: Parent / Spouse
Other-Specify _______________________
I authorize mailing to the address below, if mailing to address other than listed above.
Signature of Applicant
Date Signed (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
READ & SIGN (If record is not found, the fees are not refundable and are kept. If record is not on file, VSS will issue a "not found" letter.)
VS - 142 (9/18)
OFFICE USE ONLY
DEATH CERTIFICATE NUMBER: 142 -
DOCUMENT CONTROL NUMBER(S):
CASH
CHECK
MONEY ORDER
REMIT No.
DATE
CREDIT CARD (walk in only)
AMOUNT$
FILED BY STAFF
-
-
-
-
Parent 2: First, Middle, Last name prior to first marriage (Maiden Name) Please separate with a space between first, middle and last name.
TEXAS ONLY
SEE INSTRUCTIONS ON BACK.
STATE OF ___________________________________
Step 4 : AFFIDAVIT
ONLY applications for death certificates (NOT death verifications) submitted by
mail need to be notarized
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY
MAKING A FALSE STATEMENT ON THIS FORM OR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2
TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC.
195.003.)
Full Name on Certificate (First, Middle, Last Name, Suffix) Please separate with a space between first, middle and last name.
Make check or money orders payable to:
CITY OF BORGER
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Walk In: Same day service in most cases. Hours are Monday-Friday 8:00 am - 5:00 pm. Borger City Hall - 600 N. Main Street - Borger, Texas 79007
Copies of death certificates for deaths that occurred within the past 25 years can be requested only by immediate family members of the
person whose name is on the certificate. See Section 181.1(13) of the Texas Administrative Code for who qualifies as an immediate
family member. An immediate family member is the decedent's child, spouse, parent, sibling, or grandparent.
Applicants who are not immediate family members must provide legal documentation (such as an insurance policy listing the applicant
as the beneficiary) that documents a direct, tangible interest in the death certificate.
The applicant must include a photocopy of his or her valid photo ID issued by a governmental entity. See Section 181.28 of the
the Texas Administrative Code for a complete list of acceptable forms of identification. You also can see VSS’s page on
acceptable identification in English (http://www.dshs.texas.gov/vs/reqproc/Acceptable-IDs/) and Spanish (http://
www.dshs.texas.gov/vs/reqproc/Acceptable-IDs-(Spanish)/).
Applications for death certificates cannot be processed without a photo ID or alternate IDs and the signature of the applicant.
TEXAS DEATH CERTIFICATE APPLICATION
PLEASE PRINT. APPLICATION MUST BE ORIGINAL (INCLUDING SIGNATURE). NO CROSS OUT OR WHITE
OUT WILL BE ACCEPTED. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE
REQUEST.
Walk In Customer Checklist
Complete steps 1, 2, and 3 of the application. Please type or print clearly.
Sign and date the application.
Have current driver's license, passport or state identification ready
Have appropriate fees ready. Make checks or money orders payable to CITY OF BORGER.
Mail In / Expedited Customer Checklist
Complete steps 1, 2, and 3 of the application. Please type or print clearly.
Complete step 4 of the application: Sign and date the application in the presence of a notary public.
Enclose a copy of a current driver's license, passport or state identification.
Enclose appropriate fees. Make checks or money orders payable to CITY OF BORGER.
Verification Letter - A verification letter will include the decedent’s name, the date of death, and the county where the death occurred.
Verification letters are available for deaths that have occurred since 1903. Verification letters are not considered legal substitutes for
certified copies of death certificates. The VSS strongly recommends that applicants ensure a verification will satisfy its intended use.
For the status of your request, contact City of Borger by telephone at 1-806-273-0904 or by email at ssauls@borgertx.gov.
Mail In Orders: Processed and mailed 1 - 3 weeks after receipt of the request. Mail to: City of Borger, PO Box 5250, Borger, TX 79008-5250
Online Orders: Visit www.texas.gov to order online. Online orders are mailed 20-25 business days after receipt of the request.
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Death Certificate Application (City of Borger, Texas)

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Completed 14 July 2020

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