PAGE 1 OF 2 OFFICE OF VITAL RECORDS 07/2021
Death Certificate Application
To obtain any Minnesota death certificate, you must fill out the information on this form. You must also pay the
required fee and provide acceptable identification.
Minnesota Statutes, section 144.225, subdivision 7, and Minnesota Rules, part 4601.2600, subpart 5.
Information about the deceased person - used to find the requested death record
Deceased Person
First name (required) Middle name (required) Last name (required)
Name suffix
Date of death [MM/DD/YYYY]
(required)
Date of birth [MM/DD/YYYY]
Or Age
City of death County of death (required) State
MN
First parent’s name Second parent’s name Spouse on record (if any)
What kind of death certificate do you want?
☐ Certified death certificate with cause of death information
☐ Certified death certificate without cause of death information (only for records 1997 to today)
☐ Certified VA death certificate for Veterans Affairs-related purposes
Requester - person completing this application – by law you must supply this information
Requester
Requester name (please print)
Date of birth (MM/DD/YYYY)
Mailing address - UPS® will not deliver to PO boxes or APO addresses. Apt/Unit # City State ZIP Code™
Daytime phone (10-digit) Email
MANDATORY — Mark the boxes that describe your relationship to the deceased person:
1. ☐ A child of the subject 2. ☐ The parent of the subject 3. ☐ The sibling of the subject
4. ☐ The spouse on the record 5. ☐ The grandparent of the subject 6. ☐ The grandchild of the subject
7. ☐ Subject’s personal representative: the certified death certificate is required for the administration of the estate
8. ☐ Successor of the subject; the certified death certificate is required for the administration of the estate
9. ☐ Trustee of a trust; the certified death certificate is required for the proper administration of the trust
10. ☐ Determination or protection of a personal or property right (You must submit documentation showing this relationship)
11. ☐ Adoption agency — to complete post-adoption search (Employee ID required)
12. ☐ Attorney – I represent the subject, or a person listed in items 1-10 above.
My Minnesota Attorney License Number is:
If you are a NON-Minnesota attorney,
attach a copy of your attorney license
13. ☐ I am presenting a valid, certified copy of a U.S. court order (not a subpoena) that orders release of the death certificate to me
14. ☐ Local/state/tribal/federal governmental agency (Employee ID required) (Best practice: wait for family to verify death record).
15. ☐ I have a signed statement from a person listed above; it specifies the decedent’s full name (first, middle, last) and date of
death, the signer’s relationship to the subject of the record, and authorizes me to obtain the certificate.
16. ☐ I represent the Department of Veterans Affairs.
Sign this form in front of a Notary Public if you are applying by MAIL or FAX.
I certify that the information provided on this application is accurate and complete to the best of my knowledge. It is against the
law to provide false information to get a death certificate. You may be subject to fines, jail time or both. Minnesota Statutes,
section 144.227 and section 609.02, subdivisions 3 and 4.
Signature of requester named above Date
(if applying in person)
Notary Public
Signed or attested before me on _______ day of __________________, 20_______
Notary stamp/seal
Printed name of notary public
Notary public signature My commission expires
