Fillable Death Certificate Application Form [PDF] (New South Wales)

Fill Online, Printable, Fillable, Blank Death Certificate Application Form [PDF] (New South Wales) Form

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Death Certificate Application Form [PDF] (New South Wales)

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The Death Certificate Application Form [PDF] (New South Wales) form is 2 pages long and contains:

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  • 3 check-boxes
  • 72 other fields

Country of origin: AUSTRALIA
File type: PDF

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Certificate entitlement
This application form can only be used if the death occurred in
NSW. If you are the next of kin named on the death certificate, i.e.
spouse (married/defacto/same sex defacto), parent or child of the
deceased, the death certificate can be issued to you. If you are a
relative not listed on the certificate, the certificate can be issued to
you if the deceased had no living spouse, children or parents.
If you DO meet the above criteria, you must provide:
■
Three forms of your own ID (see below).
If you DON’T meet the above criteria, you must provide:
■
A Letter of Authority (available at: www.bdm.nsw.gov.au)
giving permission from the next-of-kin. Please include their
address, phone number and signature.
■
Three forms of ID from the next-of-kin (see below).
■
Three forms of your own ID (see below).
Identification (ID)
Please provide at least three forms of ID, one of each from
categories 1, 2 and 3. If you are unable to provide ID from
categories 1 and 2, you must still provide at least three forms of ID.
At least two of these must be from category 3.
All documents except foreign passports must be current.
Category 1
If born in Australia:
■
An Australian birth certificate
Record of
immigration status:
■
Citizenship certificate
■
New Zealand
citizenship certificate
■
New Zealand
birth certificate
Category 3
■
Medicare card
■
Credit or debit card
■
Centrelink or Department
of Veterans Affairs card
■
Security guard/
Crowd control licence
■
Tertiary education
institution ID card
Category 4
■
Recent utility account
with current residential
address
Category 2
■
Australian driver’s licence
■
Australian passport
■
Firearms licence
■
Foreign passport
■
Proof of age card
Disclosure of information
When you complete this application form, understand that you
have consented to the release of information provided, to those
agencies who may be able to validate the information in support of
your application. More information: www.bdm.nsw.gov.au
Your right to privacy
To protect your privacy, the Registry requires proof of your identity.
In line with the NSW Births, Deaths and Marriages Registration
Act 1995 and the Privacy and Personal Information Protection Act
1998, the Registry collects information to determine your eligibility
to obtain a certificate and to prevent fraud. Information may be
used for statistical purposes and by law enforcement agencies, and
other uses by law. Please read the Your Right to Privacy policy on
our website.
Online Lodging by post
You can lodge this application
online at:
www.bdm.nsw.gov.au
GPO Box 30
SYDNEY
NSW 2001
Lodging in person Phone: 13 77 88
Registry office locations
Monday to Friday 8am–4.30pm
■ 35 Regent St, Chippendale
■ 160 Marsden St, Parramatta
or at Service NSW service centres
www.service.nsw.gov.au
Service NSW
Monday to Friday (7am–7pm)
Hearing/Speech impaired
■ TTY/V oice Call 133 677
■ NRS 1300 555 727
Translating and Interpreting
■ TIS National 131 450
Death Certificate
Application
YOU CAN
COMPLETE THIS
APPLICATION
ONLINE AT:
bdm.nsw.gov.au
Form 10 Death Certificate Application. Effective: 1 July 2019
Your certificate will be mailed to you if your application was received by post and will incur a postage and handling fee.
PRINT clearly in BLACK pen and complete all details.
Do you require Priority processing of your application? Yes
Fee applies, see separate ‘Fees for Products and Services’ flyer.
Please specify the quantity you wish to receive e.g.
1
Standard death certificate
International Registered Post
Reason certicate is required
Your relationship to the deceased
APPLICANT’S DETAILS (details of person completing this form). Please provide copies of 3 forms of current identication with your application.
Family name
First given name Other given name(s)
Company name Company reference number
Address Suburb/Town/City
State/Territory
Postcode Country
Delivery Address Suburb/Town/City
State/Territory
Postcode Country
Contact number Email address
DETAILS OF DEATH CERTIFICATE REQUIRED
Date of death*
/ /
Age at death
Registration number
/
*If date unknown, period to be searched: From
/ /
To
/ /
Names of registered person
Family name
Family name at birth
First given name Other given name(s)
Place of death
Spouse details
Family name
Family name at birth
First given name Other given name(s)
Parent 1 details
Family name
Family name at birth
First given name Other given name(s)
Parent 2 details
Family name
Family name at birth
First given name Other given name(s)
PAYMENT DETAILS (complete this section for mail applications only). For schedule of fees, see Fees for Product and Services yer.
Total Amount $
.
Please debit my: AMEX Mastercard Visa OR Enclosed is a cheque*/money order
Card number
Name Expiry date
/
Signature
of cardholder
Signature
of applicant
I certify that I understand the provisions overpage
on Identification, Privacy & Disclosure and that
the information I have provided is true and correct.
A surcharge applies to credit card payments at the rate
of 1.4% for AMEX and 0.4% for Mastercard or Visa.
(Current)
(Current)
(Suburb/Town/City)
of deceased
(Current)
(If known)
(Note, each extra 10 year search or part thereof incurs a cost)
of cardholder
Death Certificate Application
(If applicable)
(If applicable)
(If different from above)
(e.g. probate, executor)
(e.g. son, mother, executor)
dd mm yyyy
dd mm yyyy dd mm yyyy
mm yyyy
✗
✗
*Cheques payable to NSW Registry of
Births Deaths & Marriages (non Priority only)
YOU CAN COMPLETE THIS APPLICATION ONLINE AT: bdm.nsw.gov.au
ABN 30 854 211 521
GPO Box 30 Sydney NSW 2001 Tel: 13 77 88
Form 10 Death Certificate Application. Effective: 1 July 2019
1
01
01
31
12
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Death Certificate Application Form PDF (New South Wales)

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Completed 15 July 2020

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