DEPARTMENT OF HEALTH AND FAMILY SERVICES
DIVISION OF HEALTH CARE FINANCING
HCF 5280 (REV. 04/03)
STATE OF WISCONSIN
CHAPTER 69.21 (1a, (2b), Wis. Stats.
DEATH CERTIFICATE APPLICATION
PENALTIES: Any person who willfully and knowingly makes 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 three years and six months, or both, per Chapter 69.24(1), Wisconsin Statutes].
THE FOLLOWING INFORMATION IS ABOUT THE PERSON COMPLETING THIS APPLICATION
YOUR Name (Please Print)
YOUR Daytime Telephone Number
YOUR Street Address
MAIL TO Address (if different)
According to Wisconsin Statute, a CERTIFIED copy of a death certificate is only available to a person with a “Direct
and Tangible Interest”. If you do not meet the criteria for boxes A – D, please refer to the information on page 2.
Check one box which indicates YOUR RELATIONSHIP to the PERSON NAMED (decedent) on the death certificate
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.)
B. I am the legal custodian or guardian of the PERSON NAMED on the death certificate
C. I am a representative authorized, in writing, by one of the aforementioned (A or B). The written
authorization must accompany this application
Specify whom 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 (includes funeral director, informant and medical certifier
named on the record).
E. I am a direct descendent of the PERSON NAMED on the death certificate (blood grandchild, great grandchild, etc.). (I
may receive an uncertified copy of either the “Fact of Death” certificate or the “Extended Fac