Fillable Request A Death Certificate (City of Providence)

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Request A Death Certificate (City of Providence)

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Please Print Clearly
Providence City Registrar, Providence City Hall, Room 104
25 Dorrance St., Providence, RI 02903
Application for a Certified Copy of a Death Record
Please complete ALL items 1
-
5 below:
1. Please fill in the information below for the
Full name
Date of death _________________ Place of death (city/town/hospital name) _______________________
Name of spouse (if married) ________________________________________
______________________
Mother’s full maiden name _______________________________________________________________
Father’s full name_______________________________________________________________________
2.
Complete
one
of the following:
I
am applying for the death record of:
my parent
my spouse
my child
my grandparent
other relative (specify):
my client. I am an attorney representing ______________________________. The name of the
law firm is ________________
________________.
my client. I am an insurance company representative. The name of the insurance company
is
.
another person (specify):________________________________________
3.
Why do you need this record? (We ask this question so that
we can supply you with a certified copy that
will be suitable for your needs.)
probate
social security
vets benefits
property title
foreign government
other (specify):
4.
Walk-in copies cost $22.00. Mail-in copies cost $25.00. Any additional copies of this record
purchased this same day cost $18.00 each. How many do you want? _____________
5.
I hereby state that the information supplied in item #2 above is true and that I am not in violation of Section
23
-
3
-
28 of the General Laws of RI (printed on the reverse side of this
form).
Please sign
_____________________________________________________ __________________
signature of person completing this form
date signed
Print your name _______________________________________
(
)
_________________
_________
phone #
Print your address_______________________________________________________________________
street or mailing address
city/town
state zip code
************************BELOW THIS LINE FOR OFFICE USE ONLY*************************
State/Local File #____________ Amt. rec’d _____
____ Rec’t #
Date sent ________ Initials_____
Birth
Death
Marriage
Number of first copies
________ _________ _________
Number of additional copies ________ _________ _________
Number of searches
________
Additi
onal years searched
_________
FOR STATE USE ONLY:
Delayed Filing
Correction
P/L
A
Section 23
-
3
-
28 of the General Laws
I understand that Section 23
-
3
-
28 of the General Laws of Rhode Island provides penalties for either of the
following v
iolations:
Any person who willfully and knowingly makes any false statement in a report, record, certificate or application
for an amendment thereof, or who willfully and knowingly supplies false information intending that such
information be used in the
preparation of any of the such report, record, or certificate, or amendment thereof . . .
. . shall be punished (if convicted) by a fine of not more than one thousand dollars ($1,000) or imprisoned not
more than one (1) year or both.
ID number: ID issued by:Type of picture ID:
VS-82D (Rev. 08/07)
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Request A Death Certificate (City of Providence)

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Completed 14 July 2020

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