Larimer County Vital Records Death Print this form, complete it and fax it to 9704986715

Decedent's Name ______________________________________________________________________   (first middle last) Date of Death ___________________________ City ____________________________ State_______ Hospital __________________________________________________________ Male  Female Age at Death: ___________________________ State of Birth: ____________________________ Relationship:   Mother  Father  Other ________________________________ Reason for request _________________________________________ Number Of Copies _______ Ship Method: Express Courier (additional charges)  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: _________________________    Driver's License # _________________________ Driver's License State: ______   DL Issue Date: ___________   DL Expiration Date: ___________ INCLUDE FRONT OF APPROVED IDENTIFICATION WITH THIS FORM. At least 1 of the following: Photo Driver's License Photo identification Card School, College/University Identification Card US Passport Foreign Passport Alien Registration/Permanent Resident Card Temporary Resident Card Employment Authorization Card US Military Identification Card Tribal Identificaton Card US Certificate of Naturalization Certificate of US Citizenship US Citizenship Identification Card Or at least 2 of the following: Work Identification/Paycheck Stub/W-2 Voter Registration Card Social Security Card DD-214 Motor Vehicle Registration/Title Probation Documents Marriage License Medicaid Card Social Services Card Hospital Birth Worksheet Acknowledgment of Paternity Document Department of Corrections Identification Card Note: When making a copy of your ID to place here, enlarge and lighten it to aid identification. This will reduce the processing time for your order.