The PH-3055 form, issued by the Tennessee Department of Health Office of Vital Records, serves a crucial purpose in the official verification of death facts within the state. This form, integral for various legal, personal, and administrative matters, requires a meticulous application process backed by a non-refundable fee of $15.00, tasked with the search of records based on the year and name provided by the applicant. Additional searches command the same fee per year, should more extensive investigation be necessary. Addressing the need for such a service reflects on the broader scope of how public records are accessed and utilized by individuals and agencies alike, ensuring that pertinent information regarding a deceased person’s details, including name, date and place of death, as well as parental information, is verifiable. It’s not merely a procedural step but a gateway to a wide range of activities that depend on death verification, from settling estates to accessing pension benefits, and even for historical or genealogical research. The form itself specifies the information required from the applicant and outlines the data that the Office of Vital Records will provide upon successful search, underlining its role in the legal and administrative framework of managing vital records in Tennessee. Beyond its primary function, the usage of the PH-3055 form encapsulates the balance between public interest for record accessibility and the state’s responsibility towards data protection and accuracy in its archival systems.
| Question | Answer |
|---|---|
| Form Name | Form Ph 3055 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | tn application death, tennessee verification death, tennessee verification death pdf, tennessee application verification death form |
TENNESSEE DEPARTMENT OF HEALTH
OFFICE OF VITAL RECORDS
APPLICATION FOR VERIFICATION OF DEATH FACTS
THIS APPLICATION MUST BE ACCOMPANIED BY A CHECK OR MONEY ORDER MADE
PAYABLE TO TENNESSEE VITAL RECORDS FOR $15.00.
Name and mailing address where verification is to be sent:
Name of Individual or Requesting Agency |
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In order for the Office of Vital Records’ staff to search the files of death records, please provide the following information from the record you are requesting:
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Year of Death |
Name of Deceased Person |
Also complete items
A fee of $15.00 is charged for the search of the year and the name entered above. This fee is charged even if no record is found. If you want to search more than one year of records, please enclose $15.00 for each additional year. The Office of Vital Records maintains death records for the past fifty (50) years. Earlier years may be obtained at the State Library & Archives.
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Full name of Deceased: ___________________________________________________________ |
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Date of Death: _______________________________________ |
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Place of Death: __________________________________________________________________ |
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Residence at Time of Death: ________________________________________________________ |
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5.Decedent’s parents:
Mother’s: ______________________ |
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Middle |
Maiden Name |
Father’s: ______________________ |
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Middle |
Last |
MAIL THIS APPLICATION TO:
Tennessee Department of Health
OFFICE OF VITAL RECORDS
Andrew Johnson Tower, 1st Floor
710 James Robertson Parkway
Nashville, TN 37243
RDA 10112 |
DO NOT WRITE BELOW. THE STAFF AT THE OFFICE OF VITAL RECORDS WILL ENTER INFORMATION.
This form is not a death certificate.
The information is transcribed from the original document.
1.Name of Decedent:
2.Sex:
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Date of Death: |
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Age at time of Death: |
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Date of Birth: |
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Place of Birth: |
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Was Decedent Ever in the Armed Forces: |
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No |
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8.Place of Death:
9.Facility Name and Address:
10.Marital Status:
11.Spouse’s Name:
12.Decedent’s Occupation – Kind of Business:
13.Decedent’s Residence:
14. Race: |
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16. Education: |
17.Father’s Name:
18.Mother’s Name:
19.Informant’s Name:
20.Informant’s Relationship:
21.Mailing Address:
22.Method – Place of Disposition:
23.Funeral Director:
24.Embalmer:
25.Name and Address of Funeral Home:
26.Medical Examiner’s Name and Address:
27.Physician’s Name and Address:
28.Date Certificate Filed: Other Information:
We were unable to locate a certificate with information given.
Verified By:
Title:
Date Verified:
RDA 10112 |