Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-05297 (Rev. 01/08)

FAX APPLICATION FOR A WISCONSIN DEATH CERTIFICATE

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

Personally identifying information requested on this form, including credit card information and your signature, will be used to process your application and payment for the requested copies. Failure to supply this information may result in denial of your request for copies of any Wisconsin Death Certificate. Your credit card number and expiration date are required. The credit card number and expiration date will only be used to process payment for the fees specified in SECTION III ­ FEES below of this FAX Application for a Wisconsin Death Certificate.

PENALTIES: Any person who willfully and knowingly makes a 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 s. 69.24(1), Wis. Stats.] INSTRUCTIONS: Please complete this form and FAX to 608-255-2035. ALL FAX APPLICATIONS ARE CHARGED FOR EXPEDITED SERVICE. SECTION I - SHIP TO INFORMATION (Print or type.) (You must complete this section for application to be processed.) 2. DAYTIME TELEPHONE NUMBER 1. FULL NAME (First , Middle, Last ) ( 3. STREET ADDRESS or P.O. BOX (You must provide a street address if you are requesting shipping by UPS.) ) APT. NUMBER

4. CITY, VILLAGE, OR TOWNSHIP

5. STATE

6. ZIP CODE (CHECK ONE)

SECTION II - APPLICANT'S RELATIONSHIP TO THE PERSON NAMED ON THE DEATH CERTIFICATE (Decedent) I am a Parent (whose parental rights have not been terminated) of the person named on the death certificate.

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 Brother / Sister Grandparent I am a representative, authorized in writing, by the person indicated by any of the above checkboxes. (The written authorization must accompany this application.) Specify the person you represent: ____________________________________________________________________________ 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: _______________________________________________________________________________________________________ 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. None of the above. I am requesting an uncertified copy only. (Copy will not be valid for legal purposes.)
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

SECTION III - FEES READ INSTRUCTIONS ON PAGE 2 OF THIS FORM BEFORE COMPLETING THIS SECTION. Mandatory fees are already filled in. Fill in additional fees for extra copies or for UPS delivery, if applicable. FEES ARE NOT REFUNDABLE IF NO RECORD IS FOUND. 1. Search Fee (includes one copy of the death certificate, if found) ........................................................ ............. $ 20.00 Fact of Death or Extended Fact of Death ...... __________ X $ 3.00 _________ Number of Copies _________ ___20.00___ ____6.00___ ___20.00 __

2. Additional Copies of the Certificate (issued at the same time as the first) Fact of Death Certificate (without cause of death and disposition) .............................

Extended Fact of Death Certificate (with cause of death and disposition) .......... ............... ___________ X $ 3.00 Number of Copies 3. Expedited Service Fee ............................................................................................................................. $ 20.00 4. Credit Card Processing Fee .................................................................................................................... $ 6.00 5. Shipping Regular Mail - No additional cost; mailed within 5 business days ............................................. $ 0.00

UPS Next Day - $17.50 in the continental U.S.; shipped within 2 business days. ........................... $ 17.50 UPS packages require a signature for delivery. NOTE: If no box is checked, the copy will be sent by regular mail. SECTION IV - CREDIT CARD INFORMATION We accept Visa, MasterCard, American Express, or Discover. TOTAL

__________ __________

CREDIT CARD NUMBER ____________________________________________________________ EXPIRATION DATE ________________________

> SIGNATURE - Credit Card Holder __________________________________________________ DATE SIGNED ____________________________
SECTION V - DEATH CERTIFICATE INFORMATION FULL NAME OF DECEDENT (First , Middle , Last Name as it appears on the certificate) PLACE OF DEATH - City, Village, or Township * NAME OF SPOUSE * (First, Middle , Last ) PLACE OF DEATH - County DATE OF DEATH (Month / Day / Year ) AGE or DATE OF BIRTH* DECEDENT'S SOCIAL SECURITY NUMBER *

*

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

VITAL RECORDS OFFICE USE ONLY

Certificate Number

FAX APPLICATION FOR WIS DEATH CERTIFICATE F-05297 (Rev. 01/08)

Page 2

INSTRUCTIONS FOR FAX APPLICATION FOR A WISCONSIN DEATH CERTIFICATE
F-05297
A CERTIFIED COPY of a death certificate issued by the State Vital Records 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, brother/sister, or grandparent of the decedent); A person authorized in writing by one of the above; * 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 is not 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).

PRE-2003 DEATH CERTIFICATES CERTIFIED COPY (A certified copy has a raised seal, will show the signature of the State Registrar, and will be printed on security paper. It can be used for legal purposes, such as settling an estate or claiming insurance benefits.) TYPE OF CERTIFICATE AVAILABLE Extended Fact of Death * TYPE OF RECIPIENT Must have a "direct and tangible interest" TYPE OF CERTIFICATE AVAILABLE Extended Fact of Death TYPE OF RECIPIENT Anyone

2003 AND LATER DEATH CERTIFICATES TYPE OF CERTIFICATE AVAILABLE Fact of Death ** Extended Fact of Death TYPE OF RECIPIENT Must have a "direct and tangible interest" TYPE OF CERTIFICATE AVAILABLE Fact of Death TYPE OF RECIPIENT Anyone

UNCERTIFIED COPY (An uncertified copy can NOT be used for legal purposes.)

* Extended Fact of Death Certificate. Cause of death and disposition included; can be used for insurance benefit claims ** Fact of Death Certificate. No cause of death or disposition included; can be used for banking and most other financial transactions