Fillable SECTION A - INFORMATION ON TYPE OF RECORD (Florida Department of Health)

Fill Online, Printable, Fillable, Blank SECTION A - INFORMATION ON TYPE OF RECORD (Florida Department of Health) Form

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

SECTION A - INFORMATION ON TYPE OF RECORD (Florida Department of Health)

On average this form takes 13 minutes to complete

The SECTION A - INFORMATION ON TYPE OF RECORD (Florida Department of Health) form is 1 page long and contains:

  • 0 signatures
  • 3 check-boxes
  • 49 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Florida Department of Health

BROWSE FLORIDA DEPARTMENT OF HEALTH (FL) 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
 
DH 727, 01/2015, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)
State of Florida
Department of Health - Vital Statistics
APPLICATION FOR FLORIDA DEATH OR FETAL DEATH RECORD
SECTION A - INFORMATION ON TYPE OF RECORD AND DECEDENT PLEASE CHECK APPROPRIATE BOX: DEATH FETAL DEATH
NAME OF DECEDENT
FIRST
MIDDLE
LAST
SUFFIX
ALIAS NAME(IF APPLICABLE)
IF MARRIED AND APPLICABLE, PRIOR SURNAME (If known)
DATE OF DEATH
DAY
YEAR (4-DIGIT)
STATE FILE NUMBER (If known)
SEX
ADDITIONAL YEARS
TO BE SEARCHED
(Required only when exact year is not known)
Below indicate the range of years to be searched
PLACE OF DEATH CITY OR TOWN
(If not known, enter Unknown )
PLACE OF DEATH COUNTY
(If not known, enter Unknown )
NAME OF SURVIVING SPOUSE AS
RECORDED ON DEATH RECORD
(if applicable and if known)
FIRST
MIDDLE
LAST
SUFFIX
SOCIAL SECURITY NUMBER (If known)
FUNERAL HOME NAME(If known)
SECTION B – FEES & PAYMENT: A RECORD SEARCH REQUIRES ADVANCE PAYMENT OF A NON-REFUNDABLE SEARCH FEE OF $5.00
1
St
CERTIFICATION - Fee of $5.00 entitles applicant to ONE certification. Check appropriate box:
Without Cause of Death With Cause of Death (See Eligibility on the reverse side of this form)
$5.00
X
1
=
$5.00
Additional Computer Certifications WITHOUT Cause of Death:
$4.00 for each subsequent certification
$4.00
X
=
Additional Computer Certifications WITH Cause of Death (See Eligibility on the reverse side of this form):
$4.00 for each subsequent certification
$4.00
X
=
Additional Years to be Searched: Required only when exact year is not known
$2.00 for each additional year. The maximum additional year search fee is $ 50.00 regardless of the total number of years to be
searched.
$2.00
X
=
RUSH ORDERS (Optional): RUSH Fees are an additional $10.00.
If you desire RUSH service, mark the outside of your envelope “RUSH” (Processing time within our office for Rush
Service is 2-3 business days; routine processing time within our office is 4-6 business days.)
Check here for RUSH Order
$
TOTAL AMOUNT ENCLOSED: Check or Money Order Payable to: Vital Statistics. (DO NOT SEND CASH)
International payments should be made by Cashiers Check or Money Order in U. S. Dollars.
Florida Law imposes an additional service charge of $15.00 for dishonored checks.
ENCLOSE COPY OF VALID PHOTO IDENTIFICATION IF
CAUSE OF DEATH REQUESTED OR YOUR ORDER WILL
NOT BE COMPLETED
$
SECTION C – APPLICANT/MAILING INFORMATION
Any person who willfully and knowingly provides any false information on a certificate, record or report required by Chapter 382, Florida Statutes, or on any
application or affidavit, or who obtains confidential information from any Vital Record under false or fraudulent purposes, commits a felony of the third degree,
punishable as provided in Chapter 775, Florida Statutes.
Applicant’s Name
TYPE OR PRINT
FIRST, MIDDLE, LAST (INCLUDING ANY SUFFIX)
Applicant Signature
If Funeral Director OR Attorney listed as Applicant and
requesting Cause of Death Information
LICENSE/BAR NUMBER
NAME OF PERSON YOU ARE REPRESENTING
If requesting cause of death, state your relationship (OR if a
funeral director or an attorney, the relationship of the person you
are representing) to the decedent.
RELATIONSHIP TO DECEDENT
HOME PHONE NUMBER
( )
ADDRESS FOR MAILING (BE SURE TO INCLUDE ANY BUILDING OR APARTMENT NUMBER.)
ALTERNATE PHONE NUMBER
( )
CITY
STATE
ZIP CODE
IF THE CERTIFICATION IS TO BE MAILED TO ANOTHER PERSON OR ADDRESS USE THE SPACES BELOW TO SPECIFY SHIP TO NAME AND ADDRESS.
SHIP TO NAME
TYPE OR PRINT
FIRST
MIDDLE
LAST (INCLUDING ANY SUFFIX)
HOME PHONE NUMBER
( )
SHIP TO STREET ADDRESS (AND APT. NO. IF APPLICABLE)
WORK PHONE NUMBER
( )
CITY
STATE
ZIP CODE
Read the FRONT AND BACK OF this application: Anyone may apply for a death certification. When cause of death information is also requested and the death occurred
less than 50 years ago, a copy of valid photo ID must accompany this application AND the applicant OR person being represented must be an eligible person as outlined
in statute (see Eligibility on the reverse of this form). Relationship to the decedent must be entered in the space provided at the bottom of this form when requesting cause
of death. Acceptable forms of valid ID are: driver's license, state identification card, passport, and/or military ID card. When requesting a death certification without cause
of death OR if the death occurred over 50 years prior to the request, photo identification is not required. If a funeral home or an attorney, see additional information under
Eligibility on reverse side of this form to ensure proper completion of this application.
DH 727, 01/2015, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)
INFORMATION / INSTRUCTIONS FOR APPLICATION FOR FLORIDA DEATH OR FETAL DEATH
This application is not to be used for requesting an amendment to a death record OR if you will need to have the certification
apostilled/exemplified by the Florida Department of State. If an amendment is required, use DH Form 433(non-medical amendment) or
DH 434 (medical amendment). For an apostille or exemplified use DH 727A.
AVAILABILITY: Some records are on file dating back to 1877, but not all events were registered.
ELIGIBILITY (Section 382.025, Florida Statutes):
WITHOUT CAUSE OF DEATH: Any person of legal age (18) may be issued a certified copy of a death record without the cause of death
on the record.
CAUSE OF DEATH INFORMATION: Cause of Death for any record over 50 years old may be issued to any applicant. Death records
less than 50 years old with the cause of death information included may only be issued to:
the decedent’s spouse or parent;
to the decedent’s child, grandchild or sibling, if of legal age;
to any person who provides a will, insurance policy or other document that demonstrates his or her interest in the estate of
the decedent,
to any person who provides documentation that he or she is acting on behalf of any of the above named persons, OR
by court order
All requests for certification of a death certificate that includes the cause of death information must state the qualifying eligibility or be
accompanied with a notarized Affidavit to Release Cause of Death Information (DH Form 1959) signed by an eligible person (form is available
on our website) and a copy of valid photo identification of both the person authorizing release and the applicant If you are uncertain about
eligibility for cause of death information, call (904) 359-6900 extension 9000 for assistance.
A funeral director or attorney representing an eligible person as defined above must include their professional license number, and the name and
relationship of the person they are representing, if requesting cause of death. If not representing someone identified above as eligible to receive
cause of death information, then a completed Affidavit to Release Cause of Death Information (DH Form 1959, available on our website) must
accompany this request.
SPECIAL NOTE: Florida clerks of court will not accept a death record with “cause of death information included” when filing probate.
DATE OF DEATH NOT KNOWN: If date of death is unknown, the entire year specified will be searched. If the year is unknown and more
than one year is to be searched, specify the span of years to be searched (Example: 1970 to present) and pay $2.00 per year for each year to be
searched.
PROCESSING TIME: Normal response time within our office is 4-6 business days; however, the processing time can exceed this
timeframe.
OPTIONS FOR RUSH SERVICE:
CREDIT CARDS: The state office currently does not accept credit cards but there is a private firm that accepts such charges and transfers the order to Vital
Statistics for a fee of $7.00 plus a $10.00 Rush Fee charged by the State Office. Telephone 1-877-550-7330 or fax the request to the private firm at 1-877-550-
7428. Call (904) 359-6900 and follow the prompts on the telephone system to be transferred free of charge to the contracted vendor. For questions, please call
the Office of Vital Statistics at (904) 359-6900, ext. 9000 and our Customer Services personnel will be able to assist you.
MAIL IN: Orders marked RUSH and with $10 rush fee included with the search fee, will be processed within our office within 2-3 days. Certification(s) will
be mailed 1
st
class mail UNLESS a prepaid self-addressed special mailing envelope is included with your request. If choosing 1
st
class mail, including a self-
addressed stamped envelope with your request is appreciated.
WALK-IN SERVICE: Is available at 1217 North Pearl Street. Orders prepaid before noon may be picked up after 3:30p.m the same day. Orders
prepaid after noon may be picked up after 10:00 a.m. the next business day.
FEES ARE NONREFUNDABLE: If no record is found, a “Not Found” statement will be issued. Fees are nonrefundable, except fees
paid for additional copies when no record is found. These are refunded on written request.
MAIL THIS APPLICATION WITH PAYMENT TO
DEPARTMENT OF HEALTH
OFFICE OF VITAL STATISTICS
ATTN: VITAL RECORDS SECTION
P.O. BOX 210,
Jacksonville, FL 32231-0042
(Street Address: 1217 North Pearl Street, Jacksonville, Florida, 32202)
PLEASE VISIT OUR WEBSITE
www.floridahealth.gov
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

SECTION A - INFORMATION ON TYPE OF RECORD (Florida Department of Health)

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 9 November 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document