REQUEST FOR COPY OF DEATH CERTIFICATE
VS-39D
Revised: 6/26/07
PLEASE PRINT
DO NOT MAIL CASH
DEATH
CERTIFICATE
OF:
FULL NAME FIRST MIDDLE LAST
SEX
M
F
DATE OF DEATH
(OR LAST KNOWN TO BE ALIVE)
PLACE OF DEATH (TOWN)
DATE OF BIRTH (MONTH/DAY/YEAR)
PLACE OF BIRTH (TOWN, STATE OR FOREIGN
COUNTRY)
FATHER’S NAME
MOTHER’S NAME
IF MARRIED, SPOUSE’S NAME
IN ACCORDANCE WITH C.G.S. §7-51a, FOR ANY DEATH OCCURRING AFTER JULY 1, 1997, ONLY THE PARTIES SPECIFIED ON
THE DEATH CERTIFICATE, SUCH AS INFORMANT, LICENSED FUNERAL DIRECTOR, LICENSED EMBALMER, CONSERVATOR,
SURVIVING SPOUSE, PHYSICIAN, TOWN CLERK, OR REGISTRAR, OR OTHER PERSONS AS AUTHORIZED BY THE
DEPARTMENT OF PUBLIC HEALTH, SHALL BE ISSUED A CERTIFIED COPY OF A DEATH CERTIFICATE CONTAINING THE
SOCIAL SECURITY NUMBER OF THE DECEDENT. ALL OTHER REQUESTERS WILL RECEIVE A CERTIFIED COPY OF THE
DEATH CERTIFICATE WITHOUT THE SOCAL SECURITY NUMBER.
PERSON MAKING THIS REQUEST:
NAME: ____________________________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
ADDRESS: __________________________________________________________________________________________________________
NUMBER
STREET
TOWN/CITY: _____________________________________
STATE: ________________ ZIP CODE: _____________________
TELEPHONE NO.: _________________________________ E-MAIL ADDRESS (optional): __________________________
RELATIONSHIP TO PERSON NAMED IN CERTIFICATE_______________________________
SIGNATURE: X___________________________________________________________________________________________
THE LEGAL FEE IS $10.00 PER COPY.
NUMBER OF COPIES WANTED:
_________________
AMOUNT ATTACHED:
$_________________________
FEE: $10.00 PER COPY MONEY ORDER MADE PAYABLE TO THE TOWN/CITY OF DEATH
MAIL THIS REQUEST WITH PAYMENT TO THE TOWN CLERK AT