Form F 05280 Lvro – Fill Out and Use This PDF

DEPARTMENT OF HEALTH SERVICES	STATE OF WISCONSIN
Division of Public Health	Chapter 69.21 Wis.Stats.
F-05280 LVRO (Rev. 12/11)	Page 1 of 2
	WISCONSIN DEATH CERTIFICATE APPLICATION
	Check #____________

PENALTIES: Any person who wilfully and knowingly makes a false application for a death certificate shall be fined not more than $1,000 or imprisoned not more than 90 days, or both, per s. 69.24(2), Wis. Stats. Any person who wilfully and knowingly obtains a death certificate for fraudulent purposes is guilty of a

Class I felony [a fine of not more than $10,000 or imprisonment of not more than 3 years and 6 months, or both, per s. 69.24(1), Wis. Stats.].

I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies of the requested death certificate in accordance with the categories listed above.

SIGNATURE	- Applicant (person named in section I, who is completing this application)	Date Signed (Month / Day / Year)

¾

Important: If you do not sign and date this form above Ï, your request cannot be processed.

WISCONSIN DEATH CERTIFICATE APPLICATION	Page 2 of 2
F-05280 LVRO (Rev. 12/11)

1.What is the difference between a “certified” and an “uncertified” copy of a death certificate?

A certified copy of a death certificate issued by the Local Vital Records Office will have a raised seal, will show the signature of the Local Registrar, and will be printed on security paper. A certified copy may be required to settle an estate or to claim insurance benefits.

State law restricts who may obtain a certified copy of a death certificate. A certified copy can only be issued to those people with a “direct and tangible interest” (section II, categories A – D) which means the following people:

An immediate family member defined as a parent (whose name is on the death certificate and whose parental rights have not been terminated), current spouse, brother, sister, grandparent, child, or current domestic partner (Declaration of Domestic Partnership registered in the Wis. Vital Records System under Chapter 770, Wis. Stats.) of the subject of the record (section II, category A).

NOTE: Grandchildren, step-parents, step-children, step-brothers and step-sisters can only obtain certified copies as section II, categories B – D.

The legal custodian or guardian of the person named on the death certificate. Legal proof, e.g., a court order of custody or guardianship, is required (section II, category B).

A person authorized in writing by one of the above. A written and notarized authorization must be attached to this application and the authorization must clearly state the relationship of the authorizing party to the subject of the record (section II, category C).

A person who can demonstrate that the death certificate is required to determine or to protect a personal or property right (section II, category D).Proof is required.

If you do not meet one of the above criteria, you cannot receive a certified copy of a death certificate.

An uncertified copy is not acceptable for legal purposes, such as claiming insurance benefits (section II, category E).

For pre-2003 death certificates, an uncertified copy of a death certificate will contain the same information as a certified copy.

For death certificates 2003 to the present, only persons named in categories A – D on the previous page may have access to information which includes exact cause of death.

				PRE-2003		2003 TO PRESENT DEATH CERTIFICATES
				DEATH CERTIFICATES
		CERTIFIED COPY		TYPE OF CERTIFICATE AVAILABLE		TYPE OF CERTIFICATE AVAILABLE
				Extended Fact of Death *		Fact of Death **
	A certified copy has a raised seal, will show the signature					Extended Fact of Death *
	of	the Local Registrar, and will be printed on security		TYPE OF RECIPIENT		TYPE OF RECIPIENT
	paper. It can be used for legal purposes, such as settling
				Must have a “direct and tangible interest”		Must have a “direct and tangible interest”
	an estate or claiming insurance benefits.)
		UNCERTIFIED COPY		TYPE OF CERTIFICATE AVAILABLE		TYPE OF CERTIFICATE AVAILABLE
				Extended Fact of Death *		Fact of Death **
	(An uncertified copy is for informational purposes only;			TYPE OF RECIPIENT		TYPE OF RECIPIENT
		It CANNOT be used for legal purposes.)
				Anyone		Anyone
*		Extended Fact of Death Certificate. Cause of death included; can be used for insurance benefit claims.

** Fact of Death Certificate. Exact cause of death omitted; can be used for banking and most other financial transactions.

2.How long will it take to process my request?

Applying in Person

In-person requests for certified and uncertified copies of death certificates are usually completed within a few minutes of application if the death certificate is on file.

.

Applying by Mail

Requests for certified and uncertified copies of death certificates are usually processed the same day they are received.

3.What identification is required when applying for a certified or uncertified copy of a death certificate?

A photocopy of the applicant’s current ID as listed below must be submitted with all mail applications.

A current ID as listed below is required when applying in-person.

The acceptable forms of identification are:

One of these:

OR

Two of these:

At least one form of ID must show your current name and current address. Expired cards or documents will not be accepted.