Free Wisconsin Death Certificate Application, F-45280 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Public Health F-05280 (Rev. 07/08)

STATE OF WISCONSIN
Chapter 69.21 (1a), (2b), Wis. Stats.

WISCONSIN 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 Street Address City / State / Zip Apt. No. MAIL TO Address (if different) City / State / Zip

APPLICANT INFORMATIO

YOUR Daytime Telephone Number

(

)
Apt. No.

RELATIONSHIP TO PERSON NAMED ON THE CERTIFICATE

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.) CHECK ONE: Spouse Child Parent Brother Sister Grandparent 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). Specify interest. ____________________________________________________________________________________________ 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 Fact of Death" certificate.) F. Other: Uncertified copy only. Copy will not be valid for legal purposes. (Please refer to the information on page 2.) Search Fee (includes one copy, if found)
Fact of Death or Extended Fact of Death (all pre-2003 deaths)

$20.00

20.00___

Each additional copy of the same certificate, issued at the same time as the first copy.

FEES

(post 2002 deaths)

Fact of Death Certificate (without cause of death and disposition) ............ ___________ X $ 3.00 ___________ (can be used for banking and most other financial transactions) Extended Fact of Death Certificate (with cause of death and disposition) ..... ___________ X $ 3.00 ___________ (can be used for insurance benefit claims) No. of Copies

(pre-2003 deaths)

NOTE: FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND.

TOTAL __________
DECEDENT'S DATE OF DEATH

DEATH INFORMATION

FULL NAME OF DECEDENT

PLACE OF DEATH * (CITY, VILLAGE, TOWNSHIP)

PLACE OF DEATH

(COUNTY)

DECEDENT'S SOCIAL SECURITY NUMBER *

DECEDENT'S AGE / BIRTHDATE *

DECEDENT'S OCCUPATION *

NAME OF DECEDENT'S SPOUSE *

NAMES OF DECEDENT'S PARENTS *

Make check or money order payable to: STATE OF WIS. VITAL RECORDS. Send completed form; stamped, self-addressed, business-size envelope; and your check or money order to: State of Wis. Vital Records, PO Box 309, Madison, WI 53701-0309

I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies of the requested death certificate in accordance with the categories listed above. SIGNATURE - Applicant (Person Completing Application)
Date Signed

* The fields marked with an asterisk (*) do not have to be completed.
The information is helpful, but not required.

OFFICE USE ONLY Certificate Number __________________________

Clear Form and Start Over

WISCONSIN DEATH CERTIFICATE APPLICATION
F-45280 (Rev 7/08)

Page 2

What is the difference between a "certified" and an "uncertified" copy of a death certificate?
A CERTIFIED COPY of a death certificate issued by our office will have a raised seal, will show the signature of the State Registrar, and will be printed on security paper. A certified copy may be required to settle an estate or to claim insurance benefits. State law restricts who may obtain a certified copy of a death certificate. A certified copy can only be issued to the following people: § § § § § An immediate family member (spouse, child, parent, sibling, or grandparent of the decedent); A person authorized in writing by one of the above (The written authorization must accompany the request and the relationship of the authorizing party to the decedent must be clearly explained.); or A person who can demonstrate that the death certificate is required to determine or to protect a personal or property right.

If you meet one of the above criteria, you may receive a certified copy of the death certificate. For pre-2003 death certificates, a certified copy will automatically include cause of death and disposition information. For 2003 and later death certificates, you must specify if you want a "Fact of Death" certificate (which does not include cause of death and disposition information) or if you require the "Extended Fact of Death" certificate (which includes cause of death and disposition information).

An UNCERTIFIED COPY of a death certificate will not be acceptable for legal purposes, such as claiming insurance benefits. § For pre-2003 death certificates, an uncertified copy of a death certificate will contain the same information as a certified copy. For 2003 and later death certificates, only persons named in the above list and direct descendants of the decedent may have access to information in the "Extended Fact of Death" certificate (which includes cause of death and disposition information).

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