HomeMy WebLinkAboutFuneral Director Certificate Request Form-FIllableREQUEST FOR CERTIFIED DEATH CERTIFICATE COPIES
FUNERAL HOMES
QUANTITY TYPE DESCRIPTION FEE
Certified Photocopy AKA Hardcopy (exact image) - lists informant $16.00
Certified Copy Computer generated copy - does not list informant $16.00
Certified Copy Short Form Computer generated - does not list cause of death $16.00
Certified VA Photocopy For Veteran’s Administration Benefits Only FREE
Certified VA Copy For Veteran’s Administration Benefits Only FREE
Certified Copy Stillbirth Hardcopy - does not list cause of death $16.00
Certified Copy Miscarriage Hardcopy - does not list cause of death $16.00
Certificate Exchanges Within 60 days of a correction $5.00
Correction of an Error More than 1 year from the date of the event $20.00
RUSH processing Certificate Orders $10.00
RUSH Legal Action Corrections, Amendments, Court Orders $25.00
HOLD ORDER IF CAUSE OF DEATH IS PENDING? YES ___ Send ____ copies with PENDING cause of death
Special Instructions: __________________________________________________________________________________
Full name of Decedent ________________________________________________________________________________
Date of Death __________________________ Place of Death ______________________________________________
(Month, Day, Year) (City and County)
Name of client you are ordering copies for: _______________________________________________________________
Relationship to Decedent: Spouse Child Grandparent/Grandchild Sibling Parent Closest Surviving
Relative (next of kin) Power of Attorney as defined by §54-1142 (1) (b-c) Personal Representative / Executor
Other (attach proof of entitlement)
Funeral Home – Name: ______________________________________________________________________________
Mailing Address: _____________________________________________________________________________________
Send Copies To: ___________________________________________________________________________________
(If other than Funeral Home)
_______________________________________________________________________________
_______________________________________________________________________________
By signing this request, I certify under penalty of perjury to the law of the State of Idaho that the foregoing is true and
correct. I attest I am ordering the certificate(s) on behalf of an individual that is legally authorized to receive said
certificate(s) according to Idaho Code §39-270 and IDAPA 16.05.01 (11) (01-03) as an immediate family member,
next of kin or as a legal representative. The name and relationship of the person are specified above.
Name: _____________________________________________________________________________
Signature:___________________________________________________________________________
Authorized Funeral Home Staff Member
For our partners who have a billing agreement on file: FAX YOUR ORDER TO: 208-334-0685
For our partners paying at the time of service: MAIL YOUR COMPLETED REQUEST FORM AND PAYMENT TO:
IDAHO VITAL RECORDS
PRIORITY SERVICES
P.O. BOX 83720
Boise, ID 83720-0036
Revised 06/2022 Page 1 of 1healthandwelfare.idaho.gov/vitalrecords