APPLICATION FOR CERTIFIED COPY OF DEATH CERTIFICATE

INFORMATION

1.  Only deaths recorded after November 1, 1912 are on file.

2.  The death certificate is the most important legal document in the settlement of the estate and insurance. It is important that the information on the certificate is correct. When you receive copies of the death certificate, check particularly spelling of names and that dates are correct.

3.  If there are incorrect items on the certificate and the death occurred less than one year ago, please notify the funeral director who filed the certificate.

4.  If there are incorrect items on the certificate and the death occurred more than one year ago, a court order may be required.  Please contact Vital Records at the above address for additional information.

5.  The fee for a certified copy of a death certificate is $10.00. Each additional copy ordered at the same time is $2.00.

6.  A five year search of our records will be made. If the record is not on file, a search fee of $6.00 will be retained.

INSTRUCTIONS

1.  Complete the information sections of this form. PLEASE PRINT.

2.  The application must be signed.

3.  PAYMENT:

Out-of-state:  Remit a bank or postal money order or a bank cashier’s check in the correct amount made payable to Mississippi State Department of Health.

Mississippi Resident:  In addition to the above methods of payment, personal checks are acceptable if drawn on a Mississippi bank; make payable to Mississippi State Department of Health.

We accept no responsibility for cash sent through the mail. Request for adjustments or refunds will be honored only if received within six months of application.

4.  Send completed application, appropriate fee and self-addressed stamped legal size envelope to the address at the top of this form.