COMMONWEALTH OF VIRGINIA

APPLICATION FOR CERTIFICATION OF A DEATH RECORD

Virginia statutes require a fee of $12.00 be charged for each certification of a vital record or for a search of the files
when no certification is made. Please make check or money order payable to State Health Department. There is a
$50.00 service charge for returned checks.
IMPORTANT: The person requesting the vital record must submit an enlarged, legible (readable) and clear photo copy of their identification. (See
list on reverse side)
REQUESTER INFORMATION DAYTIME PHONE NUMBER
NAME OF REQUESTER EMAIL (347) 610-5249
JOHN FALCON bobdolebstby@gmail.com
NAME OF BUSINESS, if applicable
JQNY
Address City State Zip Code
Check this box to receive text notifications.
22027 134TH RD SPRNGFLD GDNS NY 11413 Message & data rates may apply.
WHAT IS YOUR RELATIONSHIP TO THE PERSON NAMED ON THE CERTIFICATE? (CHECK ONE)
MOTHER FATHER PARENT ONE PARENT TWO ADULT CHILD CURRENT SPOUSE ADULT SISTER X ADULT BROTHER GRANDCHILD

GREAT-GRANDCHILD FUNERAL SERVICE LICENSEE LEGAL REPRESENTATIVE (Submit proof) OTHER (Specify)
WHAT IS YOUR REASON FOR REQUESTING THIS CERTIFICATE?
GENEALOGY
DEATH CERTIFICATE INFORMATION (Definition of certificate types are listed on the back)
Please Check: X DEATH Certificate Verification of Death
TOTAL COPIES ORDERED NAME AT DEATH (first) (middle) (last) (suffix)
1 RANDOLPH DUANE SHERMAN

DATE OF DEATH AGE AT DEATH PLACE OF DEATH (city or county in Virginia) HOSPITAL NAME (if any) SEX: X MALE
12/15/2020 61 SUFFOLK
FEMALE
FULL NAME OF MOTHER OR PARENT ONE:
(first) (middle) (last) (suffix) (maiden name if any)

FULL NAME OF FATHER OR PARENT TWO:

Is an amendment/correction needed? YES X NO If YES, enter amendment code from the reverse side. Amendment Code:
CERTIFICATE OF BIRTH RESULTING IN A STILLBIRTH (Gestation must be 20 weeks or more )
NUMBER OF COPIES NAME AT DEATH (If, applicable) (middle) (last) (suffix)
(first)
DATE OF DEATH GESTATION AT DEATH PLACE OF DEATH (city or county in Virginia) HOSPITAL NAME (if any) SEX: MALE
Weeks
FEMALE
FULL NAME OF MOTHER OR PARENT ONE:
(first) (middle) (last) (suffix) (maiden name if any)

FULL NAME OF FATHER OR PARENT TWO:

I understand that making a FALSE application for a vital record is a FELONY under state and federal law. I certify and affirm that all information on this form is true and correct.
X SIGNATURE OF REQUESTER: ____________________________________________ UNSIGNED APPLICATIONS WILL NOT BE PROCESSED.
Please indicate the address you wish the certificate(s) mailed to in the box below.
Please type or print clearly.
Name Send Completed Application To:
JOHN FALCON Division of Vital Records
Address P. O. Box 1000
22027 134TH RD Richmond, VA 23218-1000
City / State / Zip Code Contact Information:
SPRNGFLD GDNS,NY,11413 (804) 662-6200
www.vdh.virginia.gov/vital_records/
.
Submit one (1) document from the primary list OR two (2) documents from the secondary list. The State Registrar reserves the right (§32.1-271C) to accept or deny
any application submitted. The acceptable documents listed may change without prior notice.
Acceptable secondary identifications are listed on the back.
ACCEPTABLE PRIMARY IDENTIFICATION LIST
1. Photo Driver's License issued by U.S. state, territory, or jurisdiction 2. Learners/Instruction Permit issue by U.S. state, territory or jurisdiction
(unexpired or expired for not more than one year) (unexpired or expired for not more than one year)
3. Photo Identification Card issued by U.S. state, territory, or jurisdiction 4. Current Photo Identification Card - (school or employment with identification
(unexpired or expired for not more than one year) number; check cashing cards are not acceptable)
5. Unexpired U.S. Military Card of an active duty or retired member 6. U.S. Passport or passport card - unexpired
7. Unexpired Foreign Passport with Visa, I-94 or I-94W 8. U.S. Certificate of Naturalization (form N-550, N-570, N-578)
9. US Certificate of Citizenship (form N-560, N-561) 10. U.S. Citizen Identification Card (form I-197)
11. Temporary Resident Card (unexpired form I-688) 12. Employment Authorization Document (unexpired form I-766)
13. Refugee Travel Document (unexpired form I-571) 14. Resident Alien Card (unexpired form I-551)
15. Permanent Resident Card (unexpired form I-551) 16. Northern Marianas Card (unexpired form I-551)
17. Asylum - A copy of the first and last page of application for Asylum 18. Consular Report of Birth Abroad (form FS-240)
19. Certification of Report of Birth of a U.S. citizen (DS-1350) 20. Virginia Criminal Justice Agency Offender Information Form
21. U.S. Probation Offender Information Form 22. Certificate of Birth Abroad (FS-545)
.
ACCEPTABLE SECONDARY IDENTIFICATION LIST
23. U.S. Selective Service Card 24. U.S. Military Discharge Papers (form DD214)
25. Certified School Records/Transcript issued by a U.S. state or territory 26. Certificate of Enrollment issued by Virginia Department of Education
27. Life insurance policy 28. Health care insurance card - (i.e. Medicare Card, Medicaid Card)
29. Unexpired Welfare/Social Services identification card with photo issued by 30. State issued driver's license or learner's/instruction permit with photo;
municipality expired not more than 5 years
31. State issued photo identification card - expired not more than 5 years 32. U.S. Passport or passport card - expired not more than 5 years
33. Unexpired Military Dependent I.D. card with photo 34. Foreign Passport - expired not more than 5 years with a U.S. VISA
35. Unexpired weapon or gun permit issued by federal, state or municipal 36. Unexpired pilot license
government
37. Veteran's Universal Access Identification Card 38. INS form I-797 (applicable only for the individual whose name appears on
the form)
39. USCIS student or dependent SEVIS I-20 with or without USCIS stamp 40. U.S. Department of State form DS-2019 (Applicant's name must appear on
(Applicant's name must appear on the form) the form)
.
Definition of Certificate Types
Certificate of Death: Image copy of the Certificate of Death.
Verification of Death: Certified document to verify death. Data elements included on the Verification of Death are decedent's name, date of death, place of death, date of birth and
last four numbers of the social security number.
Certificate of Birth Resulting in a Stillbirth:Certificate issued on stillbirth records for gestations 20 weeks or greater. This certificate can only be issued to the parents.
.
Amendment Guidance
Most items (misspelling of the name of the registrant and/or parents, incorrect date and/or place of death, incorrect address, incorrect date of birth, incorrect sex of registrant, etc.)
on a death certificate can be corrected either administratively or judicially. There are several provisions outlined in the Code of Virginia and the Regulations Governing Vital
Records detailing how a death certificate can be amended. To properly advise the Office of Vital Records must review the death certificate.
.
Amendment Type Amendment
Comments Who can initiate Needed Documents
Code the change
Amending AMD There are several provisions outlined in the Code Immediate A written request detailing the item to be amended on the death
inaccuracies on a of Virginia and the Regulations Governing Vital Family certificate, $12 fee and requester's ID. The written request should also
death certificate Records detailing how a death certificate can be Informant include the name of the decedent and date and place of death as it
amended. To properly advise the Office of Vital Funeral Service appears on the death certificate.
Records must review the death certificate. Licensee Legal
Representative
Court Ordered JCO Court order authorizing the Office of Vital Records Immediate Requires a certified copy of the Court Order, Copy of the petition.
Changes to amend a specific item(s) on a vital record. Family Application and/or written request, $10 Administrative Fee,
Informant Certification Fee ($12 per copy) and Requester's ID.
Funeral Service
Licensee Legal
Representative