2. The information requested on this application is required by Minnesota Statutes, section 144.225, subdivision 7 and Minnesota Rules, part 4601.2600. If you do not complete all fields, the application may be returned.
4. Death Record Information
6. First Name
7. Middle Name
8. Last Name
10. Date of Death
    Date of Death
11. Date of Birth
    Date of Birth
12. City and County of Death
14. Mother's Name
16. Father's Name
18. Spouse on Record (if any)
20. Please tick one of the following:

    1. I would like a death certificate with cause of death information.
    2. I would like a death certificate without cause of death information (only available for records 1997-present)
24. Requestor Information
26. Name
27. Date of Birth
    Date of Birth
29. Mailing Address
31. City
32. State
33. Zip Code
35. Daytime Phone
36. Email
38. What is your relationship to the subject (tangible interest)?

    You must check one.

    1. I am the child of the subject.
    2. I am the parent of the subject.
    3. I am the sibling of the subject.
    4. I am the spouse on the record.
    5. I am the grandparent of the subject.
    6. I am the grandchild of the subject.
    7. I am the part responsible for filing the death record.
    8. I am a personal representative and the certified copy is required for the administration of the estate.
    9. I am a successor of the subject as defined in Minnesota Statutes, section 524.1-201 and the certified copy is required for the administration of the estate.
    10. I am a trustee of a trust and the certified copy is required for the proper administration of the trust.
    11. I have documentation that the record is necessary for the determination or protection of personal property rights (you must submit documentation showing this relationship).
    12. I represent an adoption agency and the record is needed to complete a confidential post-adoption search (you must include a copy of your employee ID).
    13. I am an attorney and I have attached proof of my licensure.
    14. I am presenting your office with a court order issued by a court of competent jurisdiction (this must be a certified copy).
    15. I represent a local, state, or federal governmental agency and the record is neccessary for the governmental agency to perform its authorized duties (you must include a copy of your employee ID).
    16. I am a representative authorized by a person listed above (you must include a notarized statement from a person listed above).
42. Signature & Notary
    Application must be signed in front of a notary if applying by mail, fax, or email.
44. I certify that the information provided on this application is accurate and complete to the best of my knowledge.
46. Requester Signature
48. Signed or attested before me on:
    Signed or attested before me on:
50. Notary Public Signature
51. My commission expires on:
    My commission expires on:
53. Notary Stamp / Seal
57. Penalties
    Any person who willfully and knowingly provides false information for a certified vital record may be sentenced up to 1 year in jail or a fine of up to $3,000 or both (Minnesota Statutes, section 144.227 and section 609.02, subdivision 3 and 4).
Leave This Blank:


58. Print Only

* indicates a required field