Fillable Death Record Request Form (Cook County Clerk's Office)

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Death Record Request Form (Cook County Clerk's Office)

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REVISED ON 1.17.2019
KAREN A. YARBROUGH I COOK COUNTY CLERK'S OFFICE
VITAL RECORDS DIVISION
P.O. BOX 641070, CHICAGO, ILLINOIS 60664-1070
Telephone: 312.603.7788 I Fax: 312.603.4899 I Web Address: cookcountyclerk.com
Please see the back of this form for further details
Number of Copies (Above)
PLEASE PRINT LEGIBLY TO ENSURE ACCURATE FULFILLMENT OF YOUR REQUEST
DEATH RECORD REQUEST FORM
Middle Name (At Death) Above
Last Name (At Death) Above
First Name (At Death) Above
Date of Death (Month/Day/Year) Above
the purposes of deception is guilty of a Class 4 Felony, as outlined in §410 ILCS 535/27(c)(f), which is punishable by up to three years in prison.
SPECIAL NOTICE TO THE SUBMITTER OF THIS DEATH RECORD REQUEST FORM
Pursuant to §410 ILCS 535/25(4)(d), "a certified copy of a death record is ONLY available to persons with a direct and tangible interest in the record, such
as one with a genealogical, personal or property interest. Anyone who willfully and knowingly uses or attempts to use any certificate and/or certification for
Submitter Phone Number Above
First Name of Submitter Above
Mailing Address of the Submitter (Street Number & Name) Above
Mailing City, Town or Village of Submitter Above
Please indicate below how you would like to receive the requested Death Certificate. If requesting the document be mailed
please include 1) A Check or Money Order; 2) A Photocopy of YOUR Photo ID; and 3) A Self-Addressed Envelope.
I would like the requested Death Certificate to be:
Mailed to me at the above address
Filled while I wait
Filled and ready when I return later
By submitting the above request for a Death Certificate, I do hereby understand and acknowledge that I have a "direct and tangible interest" in the above
record, and if and when received, I will NOT use that record for the purposes of willfully or knowingly deceiving anyone.
Signature of Submitter Above
Date This Form was Executed and Submitted Above
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Or visit one our FIVE Suburban Satellite Offices (which are located as follows):
Bridgeview
Markham
Maywood
Rolling Meadows
Skokie
50 W. Washington St. (Pedway Level, underneath the Daley Center) (Concourse Level - Rm 25)
Call (847) 759-8905 for Currency Exchange locations and hours.
Please note that a processing fee of $5 applies to Currency Exchange orders.
4.
By Visiting your Local Cook County Clerk's Office
Call our Vital Check Hotline at (866) 252-8974
Please note that a processing fee of $12.45 MAY apply for phone orders.
3.
By Visiting a Local Currency Exchange
$
2.
By Phone
)
Name on check MUST be the same person who is
entitled and legally-authorized to the Birth Record
Photocopy of government-issued photo identification
(ex. Driver's License, Passport, or State Issued ID)
A Self-Addressed Stamped Envelope
CHICAGO, ILLINOIS 60664-1070
THINGS TO REMEMBER WHEN MAILING
A Check or Money Order payable to Cook County Clerk
Temporary or Starter Checks are NOT ACCEPTED
cost $17 for the FIRST copy, and $6 for EACH ADDITIONAL COPY of the SAME RECORD. The cost is NON-REFUNDABLE
if NO RECORD IS FOUND, and/or, a CERTIFICATION THAT NO RECORD WAS FOUND is issued.
THERE ARE 4 CONVENIENT & EASY WAYS TO OBTAIN A DEATH RECORD
1.
By Mail
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KAREN A. YARBROUGH I COOK COUNTY CLERK'S OFFICE
Southwest Suburbs
Bridgeview Courthouse
South Suburbs
Markham Courthouse
West Suburbs
Maywood Courthouse
Northwest Suburbs
Rolling Meadows Courthouse
North Suburbs
Skokie Courthouse
VITAL RECORDS DIVISION
P.O. BOX 641070, CHICAGO, ILLINOIS 60664-1070
Telephone: 312.603.7788 I Fax: 312.603.4899 I Web Address: cookcountyclerk.com
DEATH RECORD REQUEST FORM INSTRUCTIONS
To obtain a copy of a birth record from the Cook County Clerk's Office, please read the following: Certified Copies of Death Records
Fill out this form and mail your request to:
Bureau of Vital Records
P.O. BOX 641070
) (708) 974-6150 (main)
) (708) 232-4150 (main)
) (708) 865-6010 (main)
) (847) 818-2850 (main)
) (847) 470-7233 (main)
Thank you for your interest in the requested Death Record. We look forward to servicing your request as accurately
and efficiently as possible. We greatly appreciate your business. Cook County Clerk, Karen A. Yarbrough
10220 S. 76th Ave, Room 238
Bridgeview, Illinois 60455
16501 S. Kedzie, Room 238
Markham, Illinois 60426
1311 Maybrook Sq., Rm 104
Maywood, Illinois 60153
2121 Euclid Ave., Room 238
Rolling Meadows, Il 60008
5600 W. Old Orchard Rm. 149
Skokie, Illinois 60077
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Death Record Request Form (Cook County Clerk's Office)

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Completed 5 August 2020

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