Arkansas Death Certificate Application Form PDF Details

The Arkansas Department of Health is responsible for issuing death certificates. In order to obtain a death certificate, you must complete the Application for a Death Certificate form and submit it to the department. The form can be downloaded from the department's website, or you may request one from the department by mail. The application must be completed in full, and supporting documentation must be provided. The department will review your application and determine whether you are eligible to receive a death certificate.

QuestionAnswer
Form NameArkansas Death Certificate Application Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdeath certificate louisiana, blank ar certificate of death form, arkansas death certificates, death certificate arkansas

Form Preview Example

 

 

ARKANSAS DEPARTMENT OF HEALTH

 

 

VITAL RECORDS, Slot 44

Date

 

4815 West Markham

 

 

Little Rock, AR 72205

 

 

DEATH CERTIFICATE APPLICATION

Only Arkansas deaths are recorded in this office. There are only a limited number of death records filed in this office for deaths prior to February 1, 1914. The fee is $10.00 for the first certified copy requested and $8.00 for each additional certified copy of the record. The fee must accompany the application. Send check or money order payable to the Arkansas Department of Health. DO NOT SEND CASH. Of the total fee you send, $10.00 will be kept to cover search charges if no record of the death is found. Only the names and dates listed will be searched for the $10.00 fee. Names and other dates submitted later will require an additional $10.00 non-refundable fee. Mail this application, a copy of your photo id and the money to the address above. Please allow 4-6 weeks for processing.

List Below All Possible Dates of Death and Names Under Which the Certificate May be Registered. (Type or Print)

1 Full Name of

First Name

Middle Name

 

Last Name

 

 

 

 

 

 

Deceased

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

Age of Deceased

Sex

2Date of Death

3. Place Where

City or Town

County

State

Death Occurred

 

 

 

If unknown, give

 

 

 

City or Town

County

State

last place of

 

 

 

residence.

 

 

 

4.Name of Funeral Home

5.Address of Funeral Home

6.Name and Address of Attending Certifier

If deceased was an infant, was it stillborn?

Yes

No

What is your relationship to the person whose certificate is being requested?

What is your reason for requesting a copy of this certificate?

Signature and telephone number of person requesting this certificate:

X

HOW MANY

1st Copy costs $10.00

Each additional copy costs $8.00

AMOUNT OF MONEY ENCLOSED

$

All requests for certificates require photo identification.

Certificates may also be ordered by the following methods:

Internet: www.vitalchek.com. The service fee and the certificate fee are charged to your credit card (Visa, Master Card, Discover or American Express). Certificates may be returned over night for the additional shipment fee.

OR

Telephone: (866) 209-9482. The service fee and the certificate fee are charged to your credit card (Visa, Master Card, Discover or American Express). Certificates may be returned over night for the additional shipment fee.

OR

Please PRINT the name and address of the person who is to receive this request on the lines below.

Walk-in: You may order a certified copy of the death record by coming into this office. Orders are accepted for same day issuance from 8:00 A.M. until 4:00 P.M. Monday through Friday. The office is located at 4815 West Markham St. Little Rock, AR 72205.

Any person who willfully and knowingly makes any false statement in an application for a certified copy of a vital record filed in this state is subject to a fine of not more than ten thousand dollars ($10,000) or imprisoned not more than five (5) years, or both (Arkansas Statutes 20-18-105.)

VR-8 (R 8/11)

How to Edit Arkansas Death Certificate Application Form Online for Free

When you would like to fill out arkansas death certificate form, it's not necessary to download and install any software - simply give a try to our online tool. FormsPal is committed to providing you the ideal experience with our tool by constantly adding new functions and improvements. With these updates, working with our tool gets better than ever! This is what you'd need to do to get started:

Step 1: Open the PDF doc inside our tool by clicking the "Get Form Button" above on this page.

Step 2: With our handy PDF editing tool, it is easy to do more than merely complete blanks. Express yourself and make your docs look professional with customized textual content put in, or optimize the file's original input to perfection - all that supported by the capability to insert stunning pictures and sign the PDF off.

To be able to finalize this form, be certain to enter the necessary information in every single field:

1. Complete your arkansas death certificate form with a number of essential fields. Collect all of the required information and be sure nothing is neglected!

Step # 1 of filling in arkansas death records 2021

2. The subsequent step would be to complete these particular blanks: Name and Address of Attending, Yes, What is your relationship to the, What is your reason for requesting, HOW MANY st Copy costs Each, All requests for certificates, Certificates may also be ordered, and Telephone The service fee and.

Writing section 2 of arkansas death records 2021

3. This next section focuses on Please PRINT the name and address, VR R , and Any person who willfully and - complete all these fields.

Step number 3 of filling out arkansas death records 2021

In terms of VR R and Please PRINT the name and address, make sure you do everything right here. Both of these could be the key fields in this page.

Step 3: Go through all the details you've inserted in the form fields and click the "Done" button. Sign up with us today and instantly access arkansas death certificate form, prepared for download. Each modification made is handily saved , enabling you to customize the pdf at a later stage anytime. FormsPal is dedicated to the confidentiality of all our users; we make certain that all information coming through our editor is kept protected.

Arkansas Death Certificate Application Form isn’t the one you’re looking for?

Related Documents