Obtaining a death certificate in Wisconsin necessitates navigating specific procedures and understanding the eligibility criteria set forth by the Department of Health Services, as delineated in the F-05297 form. This crucial document not only outlines the application process but also establishes who is entitled to receive a certified copy of the death certificate. A range of individuals from immediate family members to legal guardians, and those holding a tangible interest, have the prerogative to apply, contingent on their ability to substantiate their relationship or need for the document. Notably, the form emphasizes the process for expedited fax applications, detailing associated fees, such as search and expedited service fees, and underscores the importance of providing accurate personal identifying and credit card information to ensure the application's processing. Additionally, the form distinguishes between certified copies, which carry legal authority and include a raised seal among other specifics, and uncertified copies, which are not valid for legal purposes. Instructions on the form further clarify the validity and utility of different types of death certificates depending on the year of issuance, stressing the necessary identification for securing these documents. With penalties for false applications highlighted, the Wisconsin F-05297 form serves as a comprehensive guide for individuals seeking to obtain death certificates, an essential step for various legal and personal matters following a loved one's death.
| Question | Answer |
|---|---|
| Form Name | Wisconsin Form F 05297 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | secur, false, dhs, wisconsin blank death certificate form |
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Public Health |
Chapter 69.21(1a), (2b), Wis. Stats. |
Page 1 of 2 |
FAX APPLICATION FOR A WISCONSIN DEATH CERTIFICATE
Personally identifying information requested on this form, including credit card information and your signature, will be used to process your application and payment for the requested copies. Failure to supply this information may result in denial of your request for copies of any Wisconsin Death Certificate.
Your credit card number and expiration date are required. The credit card number and expiration date will only be used to process payment for the fees specified in SECTION III – FEES below on this FAX Application for a Wisconsin Death Certificate.
PENALTIES: Any person who willfully and knowingly makes a false application for a death certificate 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)]. Any person who willfully 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.].
INSTRUCTIONS: Please complete this form and FAX to
SECTION I - SHIP TO INFORMATION |
(Print or type.) (You must complete this section for application to be processed.) |
||
1. FULL NAME (First , Middle, Last ) |
|
DAYTIME TELEPHONE NUMBER |
|
|
|
( |
) |
|
|
|
|
3.STREET ADDRESS or P.O. BOX (You must provide a street address if you are requesting shipping by UPS.)
APT. NUMBER
4. CITY
5. STATE
6. ZIP CODE
SECTION II - APPLICANT'S RELATIONSHIP TO THE PERSON NAMED ON THE DEATH CERTIFICATE (Decedent) (CHECK ONE)
A. I am a member of the immediate family of the person named on the death certificate. (Only those listed below qualify as immediate family.) NOTE: Grandchildren,
|
CHECK ONE. |
|
Parent (whose name is on the death certificate and whose parental rights have not been terminated) |
||||||||||
B. |
|
Current Spouse |
|
|
Brother / Sister |
|
Grandparent |
|
Child |
|
|
Current Domestic Partner (registered in the Wis. Vital Records System) |
|
|
|
|
|
|
|
|
|
|
|
||||
I am the legal custodian or guardian of the person named on the death certificate. (Legal proof is required. See item 1 on page 2.) |
|||||||||||||
C. I am a representative, authorized in writing, by any of the above checkboxes (categories A and B). (The written and notarized authorization must
be attached to this application. See item 1 on page 2.)
Specify the person you represent: _______________________________________________________________________________________________
D.I can demonstrate that the information from the death certificate is necessary for the determination or protection of a personal or property right for myself/my client/my agency. (Proof is required.)
Specify your interest: _________________________________________________________________________________________________________
E. None of the above. I am requesting an uncertified copy. Copy will not be valid for legal identity or benefit purposes. See Item 1 and 2 on page 2.
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 )
SECTION III - FEES READ INSTRUCTIONS ON PAGE 2 OF THIS FORM BEFORE COMPLETING THIS SECTION.
Mandatory fees are already filled in. Fill in additional fees for extra copies or for UPS delivery, if applicable.
FEES ARE NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATIONS ARE NOT ACCEPTED.
1. |
Search Fee |
(includes one copy if found) ……………………...…… |
$ 20.00 |
___20.00 __ |
||
|
Fact of Death (without cause of death) or |
Extended Fact of Death (with cause of death) |
|
|
|
|
2. |
Additional copies of the same certificate issued at the same time as the first copy |
|
|
|
||
|
Fact of Death Certificate (without cause of death) ……………………….……... ________________________ X |
$ |
3.00 |
__________ |
||
|
|
|
number of additional copies |
|
|
|
|
Extended Fact of Death Certificate (with cause of death) …………………........ ________________________ X $ |
3.00 |
__________ |
|||
|
|
|
number of additional copies |
|
|
|
3. |
Expedited Service Fee ………..……….……………………………………………………………................………………. $ |
20.00 |
___20.00___ |
|||
4. |
Credit Card Processing Fee ……………………………………………………………………………...............………….. |
$ |
6.00 |
____6.00___ |
||
5. |
Shipping |
Regular Mail - No additional cost; mailed within five business days ………...............……………… |
$ |
0.00 |
|
|
|
|
UPS Next Day - $19.00 in the continental U.S.A.; shipped within two business days .............….... |
$ |
19.00 |
__________ |
|
|
|
UPS packages require a signature for delivery. |
|
|
|
|
|
NOTE: If no shipping box is checked, the copy will be sent by regular mail. |
TOTAL |
__________ |
|||
SECTION IV - CREDIT CARD INFORMATION We accept Visa, MasterCard, American Express, or Discover.
CREDIT CARD NUMBER ____________________________________________________________ EXPIRATION DATE ________________________
SIGNATURE - Credit Card Holder _________________________________________________ DATE SIGNED____________________________
SECTION V - DEATH CERTIFICATE INFORMATION |
|
FULL NAME OF DECEDENT (First, Middle, Last) |
DATE OF DEATH (Month / Day / Year ) |
PLACE OF DEATH - City, Village, or Township *
PLACE OF DEATH - County
AGE or DATE OF BIRTH*
NAME OF SPOUSE * (First, Middle , Last )
DECEDENT'S SOCIAL SECURITY NUMBER *
*The fields marked with an asterisk (*) do not have to be completed. The information is helpful but not required.
VITAL RECORDS OFFICE USE ONLY
Certificate Number
FAX APPLICATION FOR A WISCONSIN DEATH CERTIFICATE |
Page 2 of 2 |
|
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 State Vital Records Office will have a raised seal, will show the signature of the State 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,
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 birth 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 will contain the same information as a certified copy but it is not acceptable for legal purposes, such as claiming insurance benefits (section II, category E).
For
For death certificates 2003 to the present, only persons named in categories A – D on the previous page may have access to information that includes cause of death.
|
|
|
|
|
2003 TO PRESENT 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 of the |
|
|
TYPE OF RECIPIENT |
|
Extended Fact of Death * |
|
state Registrar, and will be printed on security paper. It can be |
|
|
|
TYPE OF RECIPIENT |
||
used for legal purposes, such as settling an estate or claiming |
|
|
Must have a “direct and tangible interest” |
|
||
insurance benefits. |
|
|
|
Must have a “direct and tangible interest” |
||
|
|
|
|
|
|
|
|
UNCERTIFIED COPY |
|
|
TYPE OF CERTIFICATE AVAILABLE |
|
TYPE OF CERTIFICATE AVAILABLE |
|
|
|
Extended Fact of Death * |
|
Fact of Death ** |
|
An uncertified copy can NOT be used for legal purposes. |
|
|
TYPE OF RECIPIENT |
|
TYPE OF RECIPIENT |
|
|
|
|
|
|
||
|
|
|
|
Anyone |
Anyone |
|
|
|
|
|
|||
* |
Extended Fact of Death Certificate. Cause of death included; can be used for insurance benefit claims |
|||||
** |
Fact of Death Certificate. No cause of death included; can be used for banking and most other financial transactions |
|||||
|
|
|
|
|
|
|
2.How long will it take to process my request?
Copies of death certificates are available from the State Vital Records Office no less than 3 weeks from the date of the death.
Applying by Fax requesting Regular Mail Shipping:
Requests for copies of death certificates may take up to 5 business days plus mail time to complete.
Applying by Fax requesting UPS Shipping:
Requests for copies of death certificates are usually completed and shipped within two business days.
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 fax applications.
At least one form of ID must show your current name and current address. Expired cards or documents will not be accepted.
The acceptable forms of identification are:
One of these: |
OR |
Two of these: |
|
Wisconsin driver’s license |
|
|
Major Credit Card |
Wisconsin photo ID |
|
card or badge with photo |
Health Insurance Card |
|
|
US Passport |
Recent dated, signed lease |
|
|
Check or bank book |
Recent utility bill or traffic |
|
|
|
ticket |
If you have questions regarding this form, please call