Parent 1: First, Middle, Last name prior to first marriage (Maiden Name) Please separate with a space between first, middle and last name.
Place of Death
Step 2 : INFORMATION FOR THE PERSON NAMED ON DEATH CERTIFICATE (PLEASE PRINT)
Reason for Request: Records Estate Insurance
Other: ____________________________
Step 3 : COST & FEES (FEES NON-REFUNDABLE)
Date of Death Date of Birth
Social Security Number
Month
Month
Day
Day
Year
Year
City
County State
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.
Select Certicate Type:
First Death Certicate
Additional Death Certificate(s)
Qty Price/each Total
Total Due
x $20.00
x $20.00
$
$
$
$
$27.95
$9.95
$13.00
x $3.00
Expedite Overnight Mail (for shipping within USA)
$8 for Overnight Mail + $5 for Expedited processing
Priority Mail (for shipping shipping to Overseas Military Address ONLY)
$4.95 for Overnight Mail + $5 for Expedited processing
USPS Express Mail (for shipping overnight to PO Box ONLY)
$22.95 for Overnight Mail + $5 for Expedited processing
COUNTY OF _________________________________
This instrument was acknowledged before me on ___________________________
by _________________________________________________________________
__________________________________
(Date)
(Name of person acknowledging)
(Notary Public’s Signature)
(Personalized Seal)
Death Verication
TEXAS DEATH CERTIFICATE APPLICATION
PLEASE PRINT. APPLICATION MUST BE ORIGINAL (INCLUDING SIGNATURE). NO CROSS OUT OR WHITE
OUT WILL BE ACCEPTED. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Step 1: YOUR INFORMATION AND SHIPPING ADDRESS (PLEASE PRINT)
Your Name (First, Middle, Last Name, Suffix) Please separate with a space between first, middle and last name.
Street Address
City
State
Zip Code
E-mail Address Daytime Phone Number
First, Middle and Last Name, Suffix (Please separate with a space between first, middle and last name.
Address to Send Certicate to if dierent than noted above
City
State
Zip Code
Your relationship to Person named
on Certificate: Parent / Spouse
Other-Specify _______________________
I authorize mailing to the address below, if mailing to address other than listed above.
Signature of Applicant
Date Signed (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
READ & SIGN (If record is not found, the fees are not refundable and are kept. If record is not on file, VSS will issue a "not found" letter.)
VS - 142 (9/18)
OFFICE USE ONLY
DEATH CERTIFICATE NUMBER: 142 -
DOCUMENT CONTROL NUMBER(S):
CASH
CHECK
MONEY ORDER
REMIT No.
DATE
CREDIT CARD (walk in only)
AMOUNT$
FILED BY STAFF
$5.00
I wish to make a voluntary contribution of $5.00 to promote healthy
early childhood by supporting the Texas Home Visitation Program
administered by the Oce of Early Childhood Coordination of
Health and Human Services.
-
-
-
-
Parent 2: First, Middle, Last name prior to first marriage (Maiden Name) Please separate with a space between first, middle and last name.
TEXAS ONLY
SEE INSTRUCTIONS ON BACK.
STATE OF ___________________________________
Step 4 : AFFIDAVIT
ONLY applications for death certificates (NOT death verifications) submitted by
mail need to be notarized
WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY
MAKING A FALSE STATEMENT ON THIS FORM OR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2
TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC.
195.003.)
Full Name on Certificate (First, Middle, Last Name, Suffix) Please separate with a space between first, middle and last name.
click to sign
signature
click to edit
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click to sign
signature
click to edit
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