Form Ph 3055 – Fill Out and Use This PDF

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				Date
	(			)
Street Address				Telephone No.
City	State			Zip

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:

____________	________________________________________________________________
Year of Death	Name of Deceased Person

Also complete items 1-5 below if you have that information. This allows the Office of Vital Records to perform a more accurate search.

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.

1.	Full name of Deceased: ___________________________________________________________
		First	Middle	Last
2.	Date of Death: _______________________________________
	Month	Day	Year
3.	Place of Death: __________________________________________________________________
	City	County		State
4.	Residence at Time of Death: ________________________________________________________
		City	County	State

5.Decedent’s parents:

Mother’s: ______________________	____________________	______________________
First	Middle	Maiden Name
Father’s: ______________________	____________________	______________________
First	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

PH-3055 (Rev.06/15)

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:

3.	Date of Death:				4.	Age at time of Death:
5.	Date of Birth:
6.	Place of Birth:
7.	Was Decedent Ever in the Armed Forces:			Yes		No	From			to

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:

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:

PH-3055 (Rev. 06/15)

RDA 10112