VitalChek - Ordering By Fax

Riverside County Recorder - Vital Records
Death Authorized Copy
Print this form, complete it and fax it to 8883876984

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:

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	________

SWORN STATEMENT

______________________________________,

(Print Name)

swear/affirm under penalty of

perjury under the laws of the State of California,that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a certified copy of the birth or death record of the following individual(s):

Name of Person Listed on Certificate	Relationship to Person Listed on Certificate

P: Name of Person Listed on Certificate	R: Relationship to Person Listed on Certificate
P:	R:
P:	R:
P:	R:
P:	R:

Sworn this	______	day of	___________,	20____, at	________________________,	_________.
	(Day)		(Month)		(City)	(State)

Sworn this ______ day of _________,

(Day) (Month)

20____, at _________________,______

(Year) (City) (State)

_____________________________________________________

(Signature)

Note: If submitting your order, you must have your sworn statement notarized using the Certificate of Acknowledgment below.

CERTIFICATE OF ACKNOWLEDGMENT

State of	_________________	)
		) ss
County of	_________________	)

State of _________________)

)ss

County of ________________)

On	_____________,	before me,	__________________________________________________________,	personally
			(insert name and title of officer)

appeared,	____________________________________________________,	who proved to me on the basis of
	(insert name of person signing)

satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

(NOTARY SEAL)

_______________________________________
Notary Signature