Request for a Certified Copy of a Death Certificate from the Town/City of Death
VS-39D Revised: 9-0-09
PLEASE PRINT DO NOT MAIL CASH
Death
Certificate
of:
Full Name of Deceased:
First Middle Last
SEX
M
F
Date of Death *
(
Month/Day/Yr):
Town of Death: Date of Birth (Month/Day/Yr): Place of Birth (Town, State or Foreign
Country):
Father’s Name: Mother’s Name: If Married, Spouse’s Name:
PLEASE NOTE: In accordance C.G.S. §7-51A, for deaths occurring on or after July 1, 1997, only the surviving spouse or next of kin may
obtain a copy of the death certificate with the decedent’s Social Security number listed on the death certificate. The Funeral Director who was in
charge of the disposition of the body may also obtain the death certificate with the Social Security number if the request for such certificate is within
60 days of the date of disposition. After this period, the Funeral Director may only receive death certificates with the Social Security number
redacted. All other requesters, others than those approved by the Department of Public Health, will receive a certified copy of the death certificate
without the decedent’s Social Security number.
PERSON MAKING THIS REQUEST:
Name: ______________________________________________________________________________________________________________
First Middle Last Name
Address: ________________________________________________________________________________________
Number Street
Town/City: __________________________________ State: ________________ Zip Code: _______________
Telephone No.: ____________________________ E-Mail Address (optional): __________________________
Relationship To Deceased: _______________________________
Signature: X______________________________________________________________
The fee for a copy of a Death Certificate from the State or Town is $ 20.00 per copy. Personal checks are
not accepted. Do not mail cash.
Number of Copies Requested: ___________ Amount Enclosed: $_________________________
Please send this request with a Postal Money Order made payable to the City or Town
Mail this request to the City/Town (for town contact information, refer to our website at www.ct.gov/dph.com).
*
Note: Copies of death or marriage certificates for events that occurred less than 4 months prior to the date of the request should be
sent to the Vital Records office in the town of the event. Refer to our website at
www.ct.gov/dph for town contact information.
