Form 523E – Fill Out and Use This PDF

APPLICATION FOR CERTIFIED MISSISSIPPI DEATH CERTIFICATE

Mississippi State Department of Health

Vital Records

P. O. Box 1700, Jackson, Mississippi 39215-1700

	FULL NAME				FIRST		MIDDLE			LAST
	OF DECEASED
	DATE OF DEATH				MONTH		DAY			YEAR(4 DIGITS)
	PLACE OF DEATH				COUNTY		CITY OR TOWN			STATE
	SEX		RACE		SOCIAL SECURITY NUMBER	AGE AT DEATH				STATE FILE NUMBER
	NAME OF FATHER OR PARENT					NAME OF MOTHER OR PARENT
	FUNERAL DIRECTOR				NAME			ADDRESS
					PERSON OR FACILITY REQUESTING COPY
	RELATIONSHIP OR INTEREST OF PERSON REQUESTING						PURPOSE FOR WHICH CERTIFIED COPY IS TO BE USED
	CERTIFICATE
	SIGNATURE OF APPLICANT								DATE

A DEATH RECORD SEARCH REQUIRES ADVANCE PAYMENT OF A NON REFUNDABLE SEARCH FEE OF $17.00 AND VALID PHOTO IDENTIFICATION.

Pursuant to Section 41-57-2 of the Mississippi Code of 1975, Annotated, and as defined by Mississippi State Board of Health Rules and Regulations, I hereby certify that I have a legitimate and tangible interest in the death record requested. I understand that obtaining a record under false pretenses may subject me to the penalty as described in Section 41-57-27 of the Mississippi Code of 1972, Annotated.

PHOTO IDENTIFICATION REQUIRED

Failure to provide the proper identification will result in the application being returned to you without processing. Acceptable forms of identification are: Valid Driver’s License, State Issued Identification Card, Passport, and/or Military Identification Card, Valid School , College or University Identification. (See back for other acceptable forms.).

MAILING ADDRESS REQUIRED REGARDLESS OF DELIVERY METHOD

Applicant Name (Type or Print)

Delivery Address, including APT number if applicable

Home phone number, including area code

DO NOT WRITE IN THE SPACES BELOW – FOR OFFICE USE ONLY

12 – 36	S.C.	SUP.
37 – 66	S.C.	P.
S.C.	C.D.	CWA.

Mississippi State Department of Health

Revised 01/2017

Form 523

INFORMATION AND INSTRUCTIONS FOR DEATH RECORD APPLICATION

Eligibility:	A certified copy of a death certificate can be issued only to a person with legitimate and tangible
	interest as defined by the Rules Governing the Registration and Certification of Vital Events.
	Primarily this is:
	1)	Parent(s) listed on the death record.
	2)	Spouse, sibling(s), or grandparent(s)/child(ren) of registrant, proof of relationship required.
	3)	Informant must be listed on death record.
	4)	Legal Guardian, guardianship papers must be provided.
	5)	Legal representative of one of the above persons, proof of representation must be provided.
	6)	Other person(s) by court order, certified copy of court order must be provided.
	7)	Funeral Home, must be the funeral home on record that took possession of the body.

For Genealogy purposes - Genealogy must be stated as purpose for certificate. Relationship to applicant must be provided. Plain paper copies are provided for genealogy purposes.

Requirements for Ordering: If applicant is spouse, parent, grandparent, sibling, child, grandchild, or informant, guardian, legal representative, then the applicant must provide a completed application and a copy of a valid photo identification of the applicant. Acceptable forms of identification are the following:

+ Photo Driver’s License	+ Photo State Issued ID	+ Employment ID
+ School, College or University ID	+ US Military ID	+ Tribal ID
+ Alien Registration/Permanent Resident Card	+ Temporary Resident Card	+ US Passport

OR two forms of identification from the following list:

+ Social Security Card	+ Utility Bill (showing address)	+ Medicaid Card
+ Snap/EBT card (showing address)	+ Work Identification	+ Veteran Universal Access ID Card

Guardian or legal representative must submit proof of guardianship/legal representation with this application. Legal representatives must provide attorney bar number, name of person represented, and their relationship to the registrant. If you are an agent of local, state or federal agency requesting a record, indicate in the space provided for “relationship” the name of the agency. If you do not have one of the above referenced documents, please contact Vital Records at 601-206-8200

Relationship or interest to Applicant: A person ordering a death certificate should enter the relationship or interest in this space.

Others must identify their relationship to the registrant clearly. For Genealogy purposes, relationship to applicant must be provided.

Nonrefundable: Vital record fees are nonrefundable, with the exception of fees paid for additional copies when no record is found.

Failure to Receive: Complaints of failure to receive certified records will be honored within 6 months of the original request. If the copy was to be returned to you by U.S. Postal Service, please allow 3 weeks after mailing the request before inquiring. Inquiry about copies ordered with payment for special courier delivery should be made within 7 days of the request. Mail returned because of insufficient address or address changes will be re-mailed if this office is notified of correct address within 6 months of request.

Options for Service: Certified copies of death records may be ordered in person, by mail, or, if paying by credit card, online or by telephone. Processing time is generally 7 – 10 working days after receipt of request. If amendment action is necessary, additional processing time will be required. Payment of fees is required at the time of ordering.

•WALK-IN SERVICE is available at 222 Marketridge Dr., Ridgeland, MS between the hours of 8:00 am and 4:30 pm. Death records are not available same day, all records will be mailed 7 – 10 business days after receipt of request.

•MAIL-IN requests, either on the form provided or as a free form request will be processed in the order received and will be returned by regular U.S. Postal Service, unless accompanied by a prepaid special courier self-addressed envelope.

•PAYMENT BY CREDIT CARD can be done using an online service or by telephone. The private company approved to handle credit card transactions for Mississippi death records can be accessed by calling 1-877-295-4229 or by visiting www.msdh.state.ms.us/phs and clicking on link for online ordering. If you have questions or need additional assistance call 601-206-8200. A recorded message outlining ordering requirements and options can be accessed by dialing 601-206-8200, option 1.

MAIL THIS APPLICATION WITH PAYMENT TO

MISSISSIPPI VITAL RECORDS

P.O. BOX 1700

JACKSON, MS 39215-1700

Mississippi State Department of Health

Revised 01/2017

Form 523