Instructions for Death Certificate Order Form

Center for Health Statistics

P.O. Box 9709

Olympia, WA 98507

360

-236-4300

To request this document in another format, call 1-800-525-0127.

Deaf or hard of hearing customers, please call 711 (Washington Relay) or email [email protected].

DOH 422-184 June 2023

Instructions for Death Certificate Order Form

Carefully read these instructions before completing and submitting the Death Certificate Order Form. Chapter 70.58A RCW and

Chapter 246-491 WAC requires all applicants to be a qualified applicant, provide identity and proof of eligibility documentation, and

provide required information to order a death certificate.

Checklist for completing the Death Certificate Order Form:

 Complete all fields on the death certificate order form, sign, and date

 A COPY of your identity document(s). Do NOT send originals.

 A copy of your proof of eligibility document(s)

 Check or money order made payable to DOH (certificate purchases are nonrefundable)

Send the order form, all documents, and payment to:

Department of Health

Center for Health Statistics

PO Box 9709

Olympia, WA 98507

If submitting the order form with a correction request, send all

documents and payment to:

Center for Health Statistics

Attn: Corrections

PO Box 47814

Olympia, WA 98504-7814

What is a qualified applicant?

A qualified applicant is a person who is eligible to receive a certificate.

Who are the qualified applicants for a long form death certificate?

Qualified applicants for a long form death certificate are: Spouse/Domestic Partner, Child, Parent, Stepparent, Stepchild, Sibling,

Grandparent, Grandchild, Great Grandparent, Legal Guardian, Legal Representative, Authorized Representative, Next of Kin (if no

one else from this list is living), Funeral Director or Funeral Establishment listed on the record (up to 12 months from the date of

death), or Government Agency or the Courts (only for official duties).

Who are the qualified applicants for a short form death certificate?

Qualified applicants for short form death certificates are the same as the long form death certificates, plus these additional qualified

applicants: A title insurer or title insurance agent handling a transaction involving real property, or a person that demonstrates the

certificate is necessary for a determination related to the death or protection of a personal or property right related to the death.

Are you one of the qualified applicants listed above to the death certificate you are requesting?

If yes, continue. You will need to provide identity and proof of eligibility documentation.

**If you are not one of the listed above, STOP. You will not receive a WA State death certificate**

What is proof of eligibility documentation?

Proof of eligibility documentation are documents that link you to the requested death certificate.

1. If you are listed on the record and your identity documentation sufficiently links you to the record (i.e. parents), your proof

of eligibility requirement is met.

2. If you are not listed on the record or your identity documentation doesn’t sufficiently link you to the record, you must

provide additional documentation to prove eligibility.

What documents will the Department of Health (DOH) accept to prove eligibility?

DOH will accept the following documents to prove eligibility:

• Copies of vital records such as certifications of birth, death, marriage, and divorce from this or another jurisdiction that link

you to the requested record

• Copies of certified court orders from a court of competent jurisdiction linking you to the record (i.e. legal representative)

• Document or letter from a government agency or courts stating the certification will be used in the conduct of official

duties (for government and court officials only)

View the Proof of Eligibility (PDF) for examples of how to prove qualifying relationship.

Center for Health Statistics

P.O. Box 9709

Olympia, WA 98507

360

-236-4300

To request this document in another format, call 1-800-525-0127.

Deaf or hard of hearing customers, please call 711 (Washington Relay) or email [email protected].

DOH 422-184 June 2023

What identity documentation will DOH accept?

DOH will accept a copy of:

• One government issued identity document (must contain photo, full name, and date of birth) that is current or expired less

than 60 days; or

• If you do not have a government issued identity document, then at least two alternate documents from the alternate list.

The alternate documents must contain matching first and last names and addresses, or in combination contains full name,

date of birth, and photograph.

View the list of acceptable identity documentation.

What information is required?

The following information is required as it appears on the death certificate:

• First and last name of the decedent

• Date of death (month and year)

• City or county where the death occurred

What is the difference between the long form death certificate and the short form death certificate?

The long form death certificate contains cause and manner of death information and social security number of the decedent. This

product might be needed to close out bank accounts or claim benefits such as life insurance policies.

The short form death certificate is a new product being offered only for deaths that were registered electronically starting January 1,

2018 to present. It does not contain cause and manner of death information or social security number of the decedent. This product

might be needed for transferring titles (e.g. vehicles), real estate transactions, and probate cases.

Check with the agency or business where you will be using the certificate to know what information it must include prior to

purchasing it.

What if I cannot provide the required documents to prove eligibility, do not have identity documents from the acceptable list, or

know the required information?

If you are unable to meet the requirements, you may submit a request for an exception. This process allows the applicant to explain

why you are unable to provide the required documentation or information.

What address do I put on the order form?

The address you provide on the order form must be the address you are REGISTERED to receive mail at. If that is not an option, put

the name of the individual registered at the address and then put “in care of” before your name (Ex. John Doe C/O Jane Doe, 101

Israel Rd SE, Tumwater, WA 98502). If filling in the form by hand, please print clearly to avoid delay in processing.

What form of payment is accepted?

We accept checks or money orders for requests mailed to DOH. Make sure your check or money order is made payable to DOH.

Important note: no refunds will be given if a record could not be located or the documentation you provided did not prove you

were eligible to receive a death certificate.

Helpful tip: To confirm that DOH has received your order over the phone, we need:

• For Checks: Check number, date it was cashed (check with your banking institution before calling DOH), and name on the

check

• For Money Orders: Money order number and date it was cashed (to find this date call the number provided on your money

order receipt)

For more information about vital records, please visit our website at https://www.doh.wa.gov/vitalrecords.

To request this document in another format, call 1-800-525-0127.

Deaf or hard of hearing customers, please call 711 (Washington Relay) or email [email protected].

DOH 422-184 June 2023

DEATH CERTIFICATE

MAIL ORDER FORM

VALIDATION SPOT

MAIL ORDERS TO:

Department of Health

PO BOX 9709

OLYMPIA WA 98507-9709

DO NOT USE ANY UNAPPROVED THIRD PARTY VENDOR TO

OBTAIN THIS FORM. DO NOT PAY A FEE FOR THIS FORM

MAKE CHECKS & MONEY ORDERS

PAYABLE TO: DOH

NO REFUNDS

FEES: (Check the box to select order type then enter the quantity.)

☐ Total number of LONG FORM certificates

x $25 =

☐ Total number of SHORT FORM certificates

x $25 =

☐

APOSTILLE: (Indicate country requesting document here)

x $15 =

SHIPPING: (expedited shipping does NOT mean expedited processing)

☐

First Class Mail (No additional charge)

$0 =

☐

*USPS Express Mail Delivery (street address or PO Box)

$26.35 =

☐

**FedEx to continental US (no PO Box)

$15 =

☐

FedEx to AK/HI/Canada/Mexico (no PO Box)

$25 =

TOTAL AMOUNT DUE: (ADD THE FEE AMOUNT + SHIPPING FOR TOTAL DUE)

FOR OFFICE USE ONLY

APOSTILLE

☐

VERIFIED

DATE: INITIALS:

☐

SENT TO SOS

DATE: INITIALS:

☐

NOTATED IN WHALES

FEE#

COUNTRY:

APPLICANT INFORMATION

NAME OF PERSON/COMPANY ORDERING CERTIFICATE (S):

ADDRESS SENDING CERTIFICATE (S) TO: (STREET ADDRESS REQUIRED FOR FEDEX ORDERS)

CITY:

STATE:

ZIP CODE:

COUNTRY:

DAYTIME TELEPHONE NUMBER:

EMAIL ADDRESS:

To receive a death certificate, you must indicate your relationship to the registrant below and sign the sworn statement that you are authorized to receive the certificate.

SELECT

RELATIONSHIP

☐

SPOUSE/DOMESTIC PARTNER

☐

CHILD

☐

PARENT

☐

STEPPARENT

☐

STEPCHILD

☐

SIBLING

☐

GRANDPARENT

☐

GRANDCHILD

☐

GREAT GRANDPARENT

☐

LEGAL GUARDIAN

☐

LEGAL REPRESENTATIVE

☐

AUTHORIZED REPRESENTATIVE

☐

COURTS

☐

GOVERNMENT AGENCY

☐

TITLE INSURER/TITLE INSURANCE AGENT – SHORT FORM ONLY – no cause of death or SSN & only available for deaths registered after 1/1/2018

☐

DETERMINATION RELATED TO THE DEATH/PROTECTION OF A PERSONAL/PROPERTY RIGHT RELATED TO THE DEATH

SHORT FORM ONLY – no cause of death or SSN & only available for deaths registered after 1/1/2018

☐

FUNERAL DIRECTOR/FUNERAL ESTABLISHMENT – ONLY VALID WITHIN 12 MONTHS FROM DATE OF DEATH

☐

PERSON WHO HAS RIGHT TO CONTROL DISPOSITION OF REMAINS UNDER RCW 68.50.160 NAMED ON THE RECORD

All the following fields must be completed to process the order.

DEATH RECORD DETAILS

FIRST NAME(S):

FULL MIDDLE NAME(S):

LAST NAME(S):

APPROXIMATE DATE OF DEATH: (MONTH & YEAR)

CITY OR COUNTY OF DEATH:

OTHER NAMES, IF KNOWN (EX. MAIDEN NAME, MARRIED NAMES, PARENTS

NAMES, ETC.):

SPOUSE(S), IF KNOWN:

DATE OF BIRTH, IF KNOWN:

PLACE OF BIRTH, IF KNOWN:

☐

I have included a COPY of my identity document(s), my proof of eligibility document(s), and the required nonrefundable fee.

See instructions for more information.

☐

By signing this form, I declare under penalty of perjury under the laws of the state of Washington that the information I have provided

is true and correct. Further, be advised that willfully providing a false statement to vital records for a certificate is a gross

misdemeanor under Washington law, RCW 70.58A.590(2).

SIGNATURE (APPLICANT) DATE SIGNED: (MM/DD/YYYY)