Form Dh 1961 – Fill Out and Use This PDF

APPLICATION FOR A FLORIDA DEATH RECORD

OFFICE OF VITAL STATISTICS

1955 U.S. 1 SOUTH, SUITE 100

ST. AUGUSTINE, FL 32086

904-825-5055 EXT 1001

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 valid photo identification must accompany this application or if a mail request, a copy of the valid photo identification, front & back, must be provided; AND the applicant OR person being represented must be an eligible person as outlined in statute (see Eligibility on the back 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. If applicant is a funeral director or an attorney, see additional information under Eligibility on back of this form to ensure proper completion of this application.

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.

SECTION A: DECEDENT INFORMATION

FIRST

MIDDLE

LAST

SUFFIX

NAME OF DECEDENT

IF MARRIED FEMALE, MAIDEN SURNAME (if known)

SEX

ALIAS NAME (IF APPLICABLE)

MONTH

DAY

YEAR (4-DIGIT)

ADDITIONAL YEARS TO BE SEARCHED

Indicate the range of years to be searched

DATE OF DEATH

(Required only when exact year of death is not known)

PLACE OF DEATH CITY OR TOWN

PLACE OF DEATH COUNTY

STATE FILE NUMBER (if known)

PLACE OF DEATH

NAME OF SURVIVING SPOUSE AS

FIRST

MIDDLE

LAST

SUFFIX

RECORDED ON DEATH RECORD

(if applicable and if known)

SOCIAL SECURITY NUMBER

FUNERAL HOME NAME

(if known)

(if known)

IMPORTANT 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.

SECTION B: APPLICANT INFORMATION

If requesting cause of death, all applicants must state their relationship to the decedent; if a funeral director or an attorney, you must enter the

relationship of the person you represent. Eligibility requirements are provided on the back of this form.

FIRST, MIDDLE, LAST (INCLUDING ANY SUFFIX)

APPLICANT’S SIGNATURE

Applicant’s Name

TYPE OR PRINT

HOME PHONE NUMBER

MAILING ADDRESS (INCLUDE APT. NO., IF APPLICABLE)

RELATIONSHIP TO DECEDENT

(

)

ALTERNATE PHONE NUMBER

CITY

STATE

ZIP CODE

(

)

Funeral Director/Attorney as Applicant

LICENSE/ BAR NUMBER

NAME OF PERSON REPRESENTED

and

THEIR RELATIONSHIP TO DECEDENT

for

Cause of Death Information

Number of copies:	WITH cause of death ____	WITHOUT cause of death _____	$______
(No personal checks)	($10.00 Each)	($10.00 Each)
$10.00 Rush fee
(Faxed orders only)			$______
			Total Due: $______
	OFFICE USE ONLY
ID #		EXP DATE:
CERTIFICATE#:	RECEIPT#:	INITIALS:

DH 1961 6/13 64V-1.0131, Florida Administrative Code (Obsoletes previous editions)

INFORMATION AND INSTRUCTIONS

AVAILABILITY: Death registration was not required by state law until 1917; however, it was many years before we had consistent registration. While there are some records on file dating back to 1877, not all events were registered.

ELIGIBILITY:

WITHOUT CAUSE OF DEATH: Any person of legal age (18) may be issued a death certification without the cause of death.

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 following individuals:

Decedent’s spouse or parent;

Decedent’s child, grandchild or sibling, if of legal age;

Any person who provides a will, insurance policy or other document that demonstrates his or her interest in the

estate of the decedent, OR

Any person who provides documentation that he or she is acting on behalf of any of the above named persons.

Requests for a death certification that includes the cause of death information must state the qualifying eligibility, or a notarized Affidavit to Release Cause of Death Information (DH 1959), which is available upon request. If after reading the above information you are still uncertain regarding your eligibility for cause of death information, call our office (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 1959) 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.

INFORMATION NEEDED: A search cannot be made without the decedent’s name and year of death. If any of the other items requested on the front of this form are unavailable, other identifying information (such as parents’ names, birthplace, etc) may be helpful if multiple records are found for common names.

APPLICANT’S SIGNATURE: Applicant’s signature is required, as well as his/her name, valid residence address and telephone number.

SECTION C: UNIQUE COUNTY INFORMATION

RUSH ORDER: Fax this completed application form, valid picture identification (enlarged 200% and lightened) and credit

card authorization forms to 904-823-4062. Your order will be processed as soon as your request is received if all information is correct and identification can clearly be read.

MAILING ADDRESS:	St. Johns County Health Department
	1955 U.S. 1 South, Suite 100
	St. Augustine, FL 32086
	904-825-5055 ext 1001

Please visit our County website @ www. stjohnschd

PLEASE VISIT THE BUREAU OF VITAL STATISTICS WEBSITE

http://www.floridahealth.gov

DH 1961 6/13 64V-1.0131, Florida Administrative Code (Obsoletes previous editions)