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BROWSE COUNTY OF SAN BERNARDINO INFORMATION SERVICES DEPT. (CA) FORMS

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County of San Bernardino – Department of Public Health
APPLICATION FOR CERTIFIED COPY OF DEATH RECORD
NOTICE: Orders received by mail must have an attached notarized sworn statement. (See instructions)
The California Health and Safety Code, Section 103526, permits only authorized persons as defined below to receive a
Certified Copy of a death record. Those who are not authorized by law to receive a Certified Copy will receive an Informational
Certified copy marked “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.” Please indicate whether
you would like an Authorized Certified Copy or a Certified Informational Copy.
The search fee is the same as the fee for Certified copy. Any questions please contact our office at (909) 381-8990.
□ I would like an Authorized Certified Copy of the record □ I would like a Certified Informational Copy.
identified on the application form. This document will be printed with a legend on the
(In order to receive an Authorized Certified Copy, you must face of the document that states, “INFORMATIONAL
indicate your relationship to the deceased from the list below) NOT A VALID DOCUMENT TO ESTABLISH IDENITY.”
(A Sworn Statement does not need to be provided)
Note: Both documents are certified copies of the original document on file. With the exception of the legend, the documents
contain the same exact information.
To receive a Certified Copy I am:
□ A parent or legal guardian of the registrant.
□ A party entitled to receive the record as a result of a court order, or an attorney or a licensed adoption agency seeking the birth
Record in order to comply with the requirements of Section 3140 or 7603 of the Family Code.
□ A member of a law enforcement agency or a representative of another governmental agency, as provided by law, who is conducting
official business.
□ A child, grandparent, grandchild, sibling, spouse, or domestic partner of the registrant.
□ An attorney representing the registrant or the registrant’s estate, or any person or agency empowered by statute or appointed by a
court to act on behalf of the registrant or the registrant’s estate.
□ A funeral director ordering certified copies of a death certificate on behalf of an individual specified in paragraphs (1) to (5), inclusive,
of subdivision (a) of Section 7100 of the Health and Safety Code.
IF MAILING APPLICATION, ATTACHED SWORN STATEMENT MUST BE NOTARIZED.
Name of Person Completing Application (PLEASE PRINT)
Printed Name
Today’s Date
Telephone Number – Area Code First
( )
Address – Number, Street
City
State
Name of Person Receiving Copies, if Different From Above
No. of Copies
For Staff Use Only
Mailing Address for Copies, if Different From Above
City
State
DECEDENT INFORMATION (PLEASE PRINT)
Name of Decedent – First (Given)
Middle
Last (Family)
Sex
Place of Death – County
Place of Death – City
Date of Birth
Date of Death – Month, Day, Year (Or Period of Years to be Searched)
Mother’s Maiden Name or Name of Spouse
Rev 01/14
County of San Bernardino – Department of Public Health
SWORN STATEMENT
(The Applicant must complete in the presence of a Notary or Vital Records Staff.)
I, ____________________________, declare under penalty of perjury under the laws of the State of California, that
(Applicant’s Printed Name)
I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a certified
copy of the birth or death record of the following individual(s):
Name of Person Listed on Certificate (Registrant)
Applicant’s Relationship to Person Listed on Certifcate
(Must be a Relationship Listed on Page 1 of Application)
Subscribed to this _______ day of ____________, 20______, at _________________________, _________________.
(Day) (Month) (City) (State)
______________________________________________________
(Applicant’s Signature)
Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of
Acknowledgement below. The Certificate of Acknowledgement must be completed by a Notary Public.
(Law enforcement and local and state governmental agencies are exempt from the notary requirement.)
CERTIFICATE OF ACKNOWLEDGEMENT
State of _________________________)
County of _______________________)
On __________before me, ______________________________, personally appeared ____________________________,
(insert name and title of officer)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to
me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the
entity upon behalf of which the person(s) acted, executed the instrument. I certify under the PENALTY OF PERJURY under the laws of the State of
California the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
(SEAL)
__________________________________________
SIGNATURE OF NOTARY PUBLIC
(January 1, 2015)
A notary public or other officer completing this certificate verifies only the
identity of the individual who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or validity of that document.
Instructions:
A. If you are requesting an Authorized Certified Copy:
1. Complete the application form, one for each individual whose death certificate you are requesting,
indicating on each how you are related to the individual (mark the appropriate box from the list).
2. Complete the Sworn Statement
NOTE: Only one sworn statement is required if you are requesting multiple certificates at the same
time; however, the sworn statement must include the name of each individual whose death
certificate you are requesting and your relationship to that individual.
a. Sign the Sworn Statement in front of a Notary Public and have it notarized
NOTE: A funeral director ordering copies on behalf of an individual specified in
paragraphs (1) to (5), inclusive, of subdivision (a) of section 7100 of the Health Safety
Code is not required to have the Sworn Statement notarized, but still needs to complete
a Sworn Statement.
3. Submit $21 for each copy you request in the form of a personal check or money order (indicate the
number of copies you would like on the application form).
4. Send the completed application form, the notarized Sworn Statement and your payment to the
mailing address below.
B. If you are requesting a certified Informational Copy (if you do not qualify to receive an
Authorized Certified Copy, see application form):
1. Complete the application form, one for each individual whose death certificate you are requesting.
2. Submit $21 for each copy you request in the form of a personal check or money order (indicate
the number of copies you would like on the application form).
3. Send the completed application form and your payment to the mailing address listed below.
C. If you wish to submit your order in person at our physical address listed below:
The Sworn Statement must be signed in the presence of an Office of Vital Records staff member (it
does not need to be notarized).
NOTE: If no record of the death is found the $21 fee will be retained for searching (as required by law)
and a Certificate of No Record will be issued.
Checks payable to: San Bernardino DPH
Address:
Vital Statistics Section
340 N. Mountain View Ave
San Bernardino, CA 92415-0038
DEATH Rev. 01/2014
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Completed 23 February 2021

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