Alabama Vital Records Death Certificate Print this form, complete it and fax it to 3342629563

ATTENTION:  Death certificates less than 25 years old are restricted records. You must be an immediate family member or demonstrate a legal right to the record in order to obtain a copy of the record (Section 22-9A-21). Anyone falsely applying for a record is subject to a penalty upon conviction of up to three months in the county jail or a fine of up to $500. Code of Alabama 1975, Section 13A-10-109. By signing, you are certifying you have a legal right to the record requested.   Decedant's Name ____________________________________________________________________________   (first middle last) Date of Death __________________ County/City __________________________________ State_______ Social Security Number ___________________________________ Date of Birth/Age ________________ Race ___________________________________________________________________ Male  Female Name of Spouse _____________________________________________________________________________   Name of Parents _____________________________________________________________________________ Relationship: Mother   Father  Other _________________________________________________ Reason for request ___________________________________________________________________________   Number Of Copies With cause of death _______   Without cause of death (not available for deaths before 1991) _______ Ship Method: Express Courier (additional charges)  Regular Mail Ship To Name _________________________________________________________________________________ Address _________________________________________________________________________________ City ________________________________________________ State ________ Zip ______________ Daytime Phone ____________________ Credit Card: Visa   MasterCard    American Express   Discover Credit Card Number _____________________________________________________ Expires _____________ Cardholder's Signature _____________________________________________________   Date _____________