Fillable Form 4.: Correcting a Death Certificate (Grimes County)

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Form 4.: Correcting a Death Certificate (Grimes County)

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U.S.A. forms for Grimes County

BROWSE GRIMES COUNTY (TX) FORMS

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Page 1 of 4
VS-172 (Rev. 09/18)
Correcting a Death Certificate
Who Can Apply for a Correction?
The funeral director named on the death certificate.
The informant named on the death certificate.
The surviving spouse or surviving parent named on the death certificate.
Medical certifier, if a fetal death certificate.
WHEN SENDING IN THE APPLICATION, PLEASE INCLUDE A PHOTOCOPY OF VALID PHOTO ID FOR THE
PERSON SIGNING SECTION 5.
How Do I Make a Correction?
Complete and sign this application. See pages 3 and
4.
Submit the
appropriate documentation. See pa
ge 2.
Submit the
appropriate fees.
See fee schedule below.
Where Do I Mail the Application?
Regular Mailing Instructions:
Please submit your application, supporting do
cuments (if required) and fees to:
DSHS – Vital Statistics Section, P.O. Box 12040, Austin, TX 78711-2040.
Expedited Service Mailing Instructions:
The order must be sent to the Vital Statistics Section via an overni
ght mail service such as: FedEx,
Lone Star, or UPS.
Please submit your application, supporting documents (if required) and fees to:
DSHS-Vital Statistics Section, MC 1966, 1100 W. 49
th
Street, Austin, TX 78756.
Fees: How much must I submit?
Fee Schedule Fee
($)
Qty
(#)
Total
($)
Filing Fees:
•
Correction to Death Certificate $15.00 = $15.00
All orders are returned free of charge by USPS regular mail. For urgent requests, orders
may be EXPEDITED by sending the order through an overnight mail service, such as:
FEDEX, LoneStar, or UPS AND selecting one of the overnight return shipping methods
below.
O
Expedite Overnight Mail (for shipping within USA)
$8 for Overnight Mail + $5 for Expedited processing
$13.00
=
O
USPS Express Mail (for shipping overnight to PO Box ONLY)
$22.95 for Overnight Mail + $5 for Expedited processing
$27.95
=
O
Priority Mail (for shipping to Overseas Military Address ONLY)
$4.95 for Overnight Mail + $5 for Expedited processing
$9.95
=
Death Certificate(s):
O
Certified Corrected Death Certificate – 1
st
Copy $20.00 X 1 =
O
Certified Corrected Death Certificate – Additional Copies $3.00 X
Grand Total
Fees
may be combined in one check or money order made payable to DSHS – Vital Statistics
Visit our website: http://www.dshs.texas.gov/vs/default.shtm (access additional forms, order certified
copies online or visit our frequently asked questions)
Page 2 of 4
VS-172 (Rev. 09/18)
What type of correction are you requesting?
Box # 1: Document Checklist
I want to… You will need one of the supporting
documents shown in Box # 2 below
Correct decedent’s name No documentation required if applicant is the
Informant or Funeral Director. If not, 1, 2, 4,
5, 6, 7, or 8
Add one AKA to the registrant’s name that is a similar name No documentation required if applicant is the
Informant or Funeral Director. If not, 9
Correct place of death 7 or 8
Correct date of birth and/or age of decedent No documentation required if applicant is the
Informant or Funeral Director. If not, 2, 5, or 9
Correct decedent’s sex No documentation required if applicant is the
Informant or Funeral Director. If not, 5 or 9
Correct birth place of decedent No documentation required if applicant is the
Informant or Funeral Director. If not, 2, 4, 5 or
9
Correct social security number of decedent No documentation required if applicant is the
Informant or Funeral Director. If not, 3
Correct marital status of decedent
(Informant must sign and submit application)
If applicant is not the Informant, then 9. If
changing status to married, must add name of
surviving spouse
Correct surviving spouse’s name
(Informant or Funeral Director must sign and submit application)
No documentation required to correct
misspellings, if applicant is the Informant or
Funeral Director. If correction is more
significant than the spelling, 9
Correct Informant’s information
(Informant or Funeral Director must sign and submit application)
Correct decedent’s parent’s first, middle or last name No documentation required if applicant is the
Informant or Funeral Director. If not, 2, 5, or 9
Correct decedent’s residence street address
(Informant or Funeral Director must sign and submit application)
No documentation required.
Correct method or place of disposition
(Funeral Director must sign and submit application)
Correct Name of Funeral Facility
(Funeral Director must sign and submit application)
9
Correct Medical Information
(Date of death and information at or below “Certified” line–items
26-41)
10
Correct Medical Information – Fetal death certificate
(Medical certifier must sign and submit application)
No documentation required.
Suggested Supporting Documents:
Documents must be original certified copies (no photocopies or notarized copies) on official letterhead or
with an original certification or seal unless otherwise specified below. Foreign documents, including
notaries, must have an apostille or legalization. All supporting documents must match the requested
correction(s) exactly and cannot be altered.
Box # 2: Supporting Documents
1 Funeral home contract or worksheet
2 Baptismal certificate - Must be within first 5 years of birth
3 Social security card of deceased - Photocopy accepted
4 Armed forces discharge papers (form DD 214) – Photocopy accepted
5 Birth certificate of deceased
6 Divorce record (limited use)
7 Medical records
8 Medical Examiner/Justice of the Peace, Police or EMS Reports
9 A certified copy of a court order affecting information shown on the death certificate.
10 Medical amendment filed by the medical certifier
Page 3 of 4
VS-172 (Rev. 09/18)
Death Certificate Correction Application
Type or Print (please use blue or black ink ONLY) Request No.____________
Section 1: What is Your Name? (Applicant’s Information)
Name (First, Middle, Last):
Address (Mailing Address, City, State, Zip):
Email Address: Telephone # (8am-5pm)
( ) -
Your relationship to Person named on the death certificate:
Funeral Director Informant Surviving Spouse/Parent Medical Certifier (Fetal Death Only)
>>>>>>>A COPY OF THE APPLICANT’S VALID PHOTO ID MUST BE ATTACHED<<<<<<<
Section 2: Death Certificate Information
Enter information as it appears on the current death certificate.
Death Certificate Number, if known:
142 - -
Decedent’s First Name:
Middle Name: Last Name:
Date of Death: Sex:
Place of Death (City or town) (County) (State)
TEXAS
Decedent’s Date of Birth:
Decedent’s Social Security Number, if known:
Section 3: What do you want to correct?
We cannot accept whiteout, strike-through, alterations, or write overs.
List items to be added,
corrected or removed
What is on the death certificate
now?
What should the death
certificate say?
Example: Decedent’s First Name Andre Andres
Example: Date of Birth August 2, 1955 August 12, 1956
IMPORTANT: Photocopies, alterations, strike-through, or write overs of
this completed application will not be accepted. Please use a new
application if you make a mistake.
Page 4 of 4
VS-172 (Rev. 09/18)
Section 4: Would you like to request a death certificate?
Check one:
 No, I would not like a certified copy of the corrected death certificate.
 Yes, I would like a certified copy of the corrected death certificate. Number requested: ______
Please verify fees and quantity ordered in the fee box on Page 1.
Section 5: Affidavit
Please sign below in the presence of a notary public. Cross-outs or white-outs will void your application.
WARNING: The Penalty for knowingly making a false statement in this form can be 2-10 years
in prison and a fine of up to $10,000. (Texas Health and Safety Code, Chapter 195).
Applicant:
Signature: Date:
Address: City: State: Zip:
Notary Public, County Clerk, or other person authorized to administer oaths
Sworn to and subscribed before me, this ______ day of ____________ 20______.
Signature: Date:
[Stamp or Seal]
Printed name and title:
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Form 4.: Correcting a Death Certificate (Grimes County)

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Completed 21 January 2021

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