Fillable Form 4: APPLICATION FOR DEATH CERTIFIC A TE

Fill Online, Printable, Fillable, Blank Form 4: APPLICATION FOR DEATH CERTIFIC A TE Form

Use Fill to complete blank online OTHERS (CANADA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 4: APPLICATION FOR DEATH CERTIFIC A TE

On average this form takes 19 minutes to complete

The Form 4: APPLICATION FOR DEATH CERTIFIC A TE form is 2 pages long and contains:

  • 0 signatures
  • 9 check-boxes
  • 71 other fields

Country of origin: CANADA
File type: PDF

BROWSE OTHERS (CANADA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
APPLICANT
DET
AILS
MAILING ADDRESS
DET
AILS
FATHER’S MOTHER’S SPOUSE’S
DETAILS
DETAILS
DET
AILS
DEA
TH
DET
AILS
ORDER
DET
AILS
Health Registries
2130 11th Avenue, Regina, Saskatchewan, S4P 0J5
Toll Free: 1-800-667-7551 Fax: 306-787-8951
APPLICATION FOR DEATH CERTIFIC
A
TE
Please read
instructions
carefully and print clearly. Incomplete applications WILL NOT be processed.
If boxes marked with an
“
*
”
are not filled in, your application is
incomplete.
1
PRODUCT
DETAILS
Type
of
Product
Requested
*
Quantity
Type
of
Product
Requested
Framing Size Certificate
($35.00)
Certified Photocopy
of
Registration
of
Death
($55.00)
Genealogical Photocopy
of
Registration
of
Death
($55.00)
*
Quantity
2
DETAILS
OF
PERSON NAMED
ON
CERTIFICATE
[“Subject”]
3
*
Subject’s
Last Name
at Death
4
*
Subject’s
First Given
Name
5
Subject’s Second Given
Name(s)
6
Subject’s Last Name
at Birth
8
*
Subject’s
Place
of
Death
- City/Town/Village/Other
7
*
Subject’s
Date
of
Death
- Month/Day/Year
9
Death Registration
Number
,
Saskatchewan
10
Subject’s Date
of
Birth
-
Month/Day/Year
11
Subject’s Place
of
Birth - City/Town/Village/Other AND Province/State AND
Country
12
*
Subject’s
Age
at Death
13
Subject’s Address Prior
to
Death
–
Street Address AND City/town/Village/Other AND Province/State AND
Country
14
*
Subject’s
Marital
Status
Never
Married
Married
W
idowed
Divorced
Common Law
15
Subject’s Spouse’s Last Name
at Birth 16
Spouse’s First Given
Name 17
Spouse’s Second Given
Name(s) 18
Spouse’s Current Last
Name
19
Common Law Spouse’s Last Name at
Birth 20
Common Law Spouse’s First Given
Name
21 Common Law Spouse’s Second Given Name(s)
22
Common Law Spouse’s Current Last Name
23
Subject’s Mother’s Last Name
at Birth 24
Mother’s First Given
Name 25
Mother’s Second Given
Name(s) 26
Mother’s Current Last
Name
27
Mother’s Place
of
Birth
–
City/Town/Village/Other AND Province/State AND
Country
28
Subject’s Father’s Last Name
At Birth 29
Father’s First Given
Name 30
Father’s Second Given
Name(s) 31
Father’s Current Last
Name
32
Father’s Place
of
Birth
–
City/Town/Village/Other AND Province/State AND
Country
33
THE FOLLOWING MUST BE COMPLETED BY THE PERSON APPLYING FOR THE DEATH CERTIFICATE
[“Applicant”]
*A
readable photocopy
of the
Applicant’s identification MUST
be
attached
to
this Application
for
Death
Certificate.
34
*
Applicant’s
First Given
Name
35
Applicant’s Second Given
Name(s) 36
*
Applicant’s
Current Last
Name
37
*
Mailing
Address
-
Apartment
#-
Street
#
-
Street Name
-
P.O.
Box 38 If
Mailing Address
is to a
Business,
Attention:
39
*
City/Town/Village/Other 40
*
Province/State 41
*
Country
43
Telephone
- Home
44
Telephone
- Work Cell 4
5 Email
42
Postal
/ Zip Code
46
*
Reason
Why Certificate
is Requested 47
*
Applicant’s
Relationship
to
Person Named
on Certificate
Spouse
Mother
Father
Other
Parent
Daughter
Son
Other:
____________________________________________________
48
*
Method of
Delivery Requested
Mailed
Picked Up
Urgent Service
49
*
Payment
Method: CANADIAN FUNDS
ONLY 50
*
Payment
Amount
Cash
- In
Person
Only
Cheque
or
Money Order
- Payable to eHealth
Debit
or
Saskatchewan
IF
Visa
,
MasterCard
(Complete Payment Information Form and attach to Application)
51
*
Signature
of Applicant
52
*
Date
Applicant Signed Application
- Month/Day/Year
eHS-VS018-2021 03 Health Registries
*
A
readable photocopy
of the
Applicant’s identification MUST
be
attached
to
this Application
for
Death
Certificate.
Health Registries
Payment Information Form
Payment Method
Name on Card
Cardholder Signature ______________________________
Payment
Fees
• Do not send cash. It is against postal regulations to send cash through the mail.
• Persons living outside of Canada should obtain a Canadian money order.
• Payments by Cheque or Money Order should be made payable to “eHealth Saskatchewan”. Payments by cheque will be held
for 6 business days until Health Registries receives notification from the bank that the cheque has cleared.
• Urgent Service – Additional Fee of $30.00 - Where rush service is required for a birth, death, or marriage certificate, clients
may be able to request this Urgent Service option. If the application is complete, the information agrees with our records and
the event is registered, the order will be processed as soon as possible.
o In order to request Urgent Service, one of the following criteria must be met.
a) Immediate Travel – the client has already booked their holiday. The client must provide proof of the booking
(i.e. trip itinerary).
b) Emergency Travel – the client must travel due to personal emergency (i.e. family death occurred out of
province).
o You can request your documents be sent by courier or you can pick-up. Documents are available for pick-up during
regular business hours in Regina only.
o When picking up the documents, the following must be provided or the document will not be released:
• the client must present identification
• if picking up for someone else, the person picking up the document must have written authorization from the
other party; plus identification
o The Urgent Service fee is $30.00 and is charged on a per order basis in addition to the cost of the requested
documents.
• Certificates –$35.00 or $40.00
o
T
he certificate contains information extracted from the original registration.
• Certified Photocopies of Registration –$55.00
o A certified photocopy of a registration is a duplicate of the original registration.
• Genealogical Photocopies of Registration – Fee $55.00
o A genealogical photocopy of a Registration is a duplicate of the original registration and is stamped “For Genealogy
Only”.
• Registration Search – $25.00 for each search period of 3 or less consecutive years
o The fee will be charged if a search of the registry is requested and no product is issued.
eHS-VSR-2021-03
Total Amount Enclosed / Authorized $________________________________________
Expiry Date _____/______
Card Number
(Excludes Visa and MasterCard Debit)
Visa MasterCard
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 4: APPLICATION FOR DEATH CERTIFIC A TE

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 8 September 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document