D.C. Vital Records Death Certificate Print this form, complete it and fax it to 8775532119

Decedent's Name ______________________________________________________________________   (first middle last) Date of Death ___________________________ City ____________________________ State_______ Hospital __________________________________________________________ Male  Female Relationship:   Mother  Father  Other ________________________________ Reason for request _________________________________________ Number Of Copies _______ Ship Method: FedEx Priority   Regular Mail Ship To Name ______________________________________________________________________ Address ______________________________________________________________________ City __________________________________________ State ________ Zip _________ Phone Number __________________________________________ Credit Card: Visa   MasterCard    American Express   Discover Credit Card Number ______________________________________________ Expires ________ Cardholder's Signature ______________________________________________   Date ________ Applicant's Signature ______________________________________________   Date ________ Applicant's Email ______________________________________________ Applicant's DOB ______________   SSN (last 4 digits) __________ Credit Card Billing Address Name ______________________________________________ Address ____________________________________________ City _________________________ State ____ Zip ________