Fillable APPLICATION FOR CERTIFIED COPY OF DEATH RECORD Santa (HSA)

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APPLICATION FOR CERTIFIED COPY OF DEATH RECORD Santa (HSA)

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HSA 885-2 REVISED 12/23/2019
APPLICATION FOR CERTIFIED COPY OF DEATH RECORD
Santa Cruz County Office of Vital Records
INSTRUCTIONS:
1. Complete a separate application form for each person’s death record requested.
2. An Authorized Certified Copy of a death record will establish the identity of the decedent. An Informational
Certified Copy contains the same information, but will not establish the identity of the decedent. California law
permits only certain persons, as listed on the application, to receive Authorized Certified Copies of death records.
Anyone else may receive only an Informational Copy, marked with the legend “Informational, Not a Valid
Document to Establish Identity.”
3. In the top section of the application, specify whether you are requesting an Authorized Certified Copy or an
Informational Certified Copy. If you are requesting only an Informational Copy, you do not need to complete the
rest of the upper section or the sworn statement on the last page; just complete the “Death Certificate
Information” and “Application Information” sections.
4. SWORN STATEMENT:
For an Authorized Certified Copy, you must complete the upper section of the application, identifying your
relationship to the decedent, and you must sign the sworn statement.
If you apply in person, you must sign the sworn statement in the presence of the Office of Vital Records staff.
If you mail your request, your sworn statement and signature must be notarized by a Notary Public. (To find a
Notary Public, see your local yellow pages or contact your banking institution.) Any request for an Authorized
Certified Copy that does not include a notarized sworn statement will be returned without processing. Law
enforcement and local and state government agencies are exempt from the notary requirement.
PLEASE NOTE: Only one notarized sworn statement is required for multiple certificates requested at the same
time; however, the sworn statement must include the name of each individual whose death certificate you wish to
obtain, and your relationship to that individual.
5. Complete the Death Certificate Information section, providing all the information you have available to identify
the death record. If the information you furnish is incomplete or inaccurate, we may not be able to locate the
record. Complete the Applicant Information section and provide your printed name and signature where
indicated.
6. You must complete the application with the correct address information in order to insure prompt processing.
7. Submit $21 for each Authorized Certified Copy or Informational Certified Copy requested. Indicate the
number of copies you want and which type you want, and include sufficient payment with this application, in the
form of a personal check or a postal or bank money order (International Money Order for out-of-country requests)
made payable to HSA Vital Statistics.
Submit this application with the sworn statement and payment:
(by mail, statement notarized:) (in person:)
Office of Vital Records Office of Vital Records
P.O. Box 962 1430 Freedom Boulevard, Suite A
Santa Cruz CA 95061 Watsonville CA 95076
For deaths that occurred before 2018, contact the County Recorder Office, 701 Ocean Street #230, Santa
Cruz, CA 95060; Tel. (831) 454-2800.
The Office of Vital Records is open Monday-Friday from 9:00 - 4:00. Questions? You can call us at
(831) 763-8430, or e-mail us at vitalstats@santacruzcounty.us.
If the death occurred over six weeks ago, you can also obtain a death certificate via the Internet, by logging on to
www.vitalchek.com, using your credit card to process your request, for an additional fee of about $13.
HSA 885-2 REVISED 12/23/2019
APPLICATION FOR CERTIFIED COPY OF DEATH RECORD
Santa Cruz County Office of Vital Records
DO NOT Complete This Application Before Reading the Instructions on the Attached Page
Please indicate whether you are requesting an Authorized Certified Copy or an Informational Certified Copy.
______________________________________________________________________________________________________
□ I would like an Authorized Certified Copy. This copy will establish □ I would like an Informational Certified Copy. This
the identity of the decedent. To receive an Authorized Certified document will be printed with a legend that reads
Copy, you must indicate your relationship to the decedent, by “Informational, Not a Valid Document to Establish Identity.”
selecting from the list below, and complete the attached sworn Anyone may receive an Informational Copy; you are
statement. If applying by mail, you must have the sworn statement not required to select from the list below or submit the
notarized (unless you are with a law enforcement or state or local sworn statement.
government agency).
______________________________________________________________________________________________________
I am (check one):
□ A parent or legal guardian of the decedent.
□ A child, grandparent, grandchild, sibling, spouse, or domestic partner of the decedent.
□ A party entitled to receive the record as a result of a court order.
□ A member of a law enforcement agency or a representative of another government agency, as provided by law, who is conducting official
business.
□ An attorney representing the decedent or the decedent’s estate, or any person or agency empowered by statute or appointed by a court
to act on behalf of the decedent or the decedent’s estate. (If you are requesting an Authorized Certified Copy under a power of attorney,
include a copy of the power of attorney with this application form.)
□ A funeral director ordering certified copies of a death certificate on behalf of an individual specified in paragraphs (1) to (5), inclusive, of
subdivision (a) of Section 7100 of the Health and Safety Code.
DEATH CERTIFICATE INFORMATION (PLEASE PRINT OR TYPE)
Name on Certificate – First Name
Name on Certificate – Middle Name
Name on Certificate – Complete Last Name
City or Town Where Death Occurred
County Where Death Occurred
Date of Death – Month, Day, Year (If unknown, enter approximate date of death)
Sex
Female Male
APPLICANT INFORMATION (PLEASE PRINT OR TYPE)
Your Printed Name and Signature
Telephone Number – Area Code First
( )
Mailing Address – Number, Street
City
State
ZIP Code
Name of Person Receiving Copies, if Different From Above
No. of Copies
Amount Enclosed
$
E-mail Address (optional)
Mailing Address for Copies, If Different From Above
City
State
ZIP Code
DEATH
■
HSA 885-2 REVISED 12/23/2019
SWORN STATEMENT
I, ________________________________________, declare, under penalty of perjury under the laws of the State of California,
(Your Printed Name)
that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a
certified copy of the birth or death record of the following individual(s):
Name of the Person Listed on the Certificate
Your Relationship to the Person Listed on the Certificate
Declared this ________ day of ______________________, 2020, at ____________________________________, ___________.
(Day) (Month) (City) (State)
______________________________________________________
(Signature)
Note: If submitting your order by mail, you must have your sworn statement notarized, using the Certificate of
Acknowledgment below. The Certificate of Acknowledgement must be completed by a notary public. (Law
enforcement and local and state government agencies are exempt from the notary requirement.)
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CERTIFICATE OF ACKNOWLEDGMENT
State of ______________________________)
) ss
County of _____________________________)
On ________________________, before me, _________________________________________________________,
(here insert name and title of the officer)
personally appeared ______________________________________, who proved to me on the basis of satisfactory evidence to be
the person whose name is subscribed to the within instrument, and acknowledged to me that he/she executed the same in his/her
authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted,
executed the instrument. I certify under penalty of perjury under the laws of the State of California that the foregoing paragraph is
true and correct.
WITNESS my hand and official seal.
(NOTARY SEAL)
__________________________________________
NOTARY SIGNATURE
A notary public or other officer completing this certificate verifies only the
identity of the individual who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or validity of that document.
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APPLICATION FOR CERTIFIED COPY OF DEATH RECORD Santa (HSA)

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Completed 21 February 2021

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