District of Columbia Death Certificate Request

For District of Columbia Occurrences Only

Death Application Instructions

The death transcript request form contains 13 questions. A separate copy of the request form

should be completed for each person whose death record is being requested. However, multiple

copies of a single death record may be requested on the same form.

Items 1-4:      Information about the deceased.

Items 5:          Information about the record being requested.

Note:              Persons entitled to purchase a vital record birth or death certificate included:

* The registrant

* An immediate nuclear family member

* A legal guardian

* A legal representative

Item 6a:          Please indicate the total number of certificates that you are requesting.

Item 6b/a:      Please indicate the number of requested copies of certificates on which you wish to have the cause of death included.

Item 6b/b:      Please indicate the number of requested copies of certificates on which you wish to have the cause of death omitted.

Item 6c:          Please indicate the total amount of money that you are enclosing. This amount should equal the requested number of transcripts multiplied by $18.

If you send your request by mail, please enclose a check or money order payable to the DC Treasurer. The cost of either type of transcript is $18.

Item 7:            The requester's relationship to the deceased.

Item 8:            Please sign your signature once the mail-in form has been completed.

Item 9:            Please date the form.

Items 10-13: Information about the designated recipient of the certificate(s).

After you print and sign your request, mail or bring the form and a copy of your picture ID with

your payment to:

Vital Records Division

825 North Capitol Street, NE, First Floor

Washington, DC 20002

(202) 671-5000

If record is not located a "Certificate of Search" will be issued and the payment for the search is

non-refundable.

Mail-In Form

1. Name of Deceased: _____________________________________

2. Social Security Number of Deceased: - -

3. Sex: Male Female

4. Date of Death: / / (mm/dd/yyyy)

5. Death Certificate No: (if known) ____ ____________

6a. Total number of copies of certificate requested: @ $18.00 each:

6b.(a) Number with cause of death included: _____________

     (b) Number with cause of death omitted: ______________

6c.Total Amount Enclosed: $__________________

7. Relationship to Deceased: Mother Father Spouse

     Other

8. Signature of Requester: __________________________________

9. Date: ____/_____/________

Make Check/Money Order Payable to: DC Treasurer

Mail Certificate(s) to:

     10. Name:_____________________________________________

     11. Address:____________________________________________

     12.City/State/Zip Code ___________________________________

     13. Day Phone: (required) _________________________________

*Copy of Requester's Photo ID is Required!

Instructions to be completed:

1. Print, sign, date form and a copy of requester's photo ID

2. Enclose check / money order payable to: DC Treasurer

3. Mail to: Government of the District of Columbia

          Department of Health

          Vital Records Division

          825 North Capitol Street, NE, First Floor

          Washington, DC 20002

          Phone: (202) 671-5000

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