RESET PRINT SAVE AS

Bureau of Vital Records Request for Copy of Death Certificate

For Office Use Only — State File Number / Serial Number Order Number
INFO

CUSTOMER MAIL IN CHECKLIST

Please visit the Bureau of Vital Records website https://azdhs.gov/
licensing/vital-records/index.php for the following information:  Clear photocopy of the front and back of your valid, signed
government photo ID OR have your signature notarized
x Fees
x Locations, office hours, and availability of services  Proof of relationship enclosed if required (birth certificates,
x Eligibility requirements and acceptable identification certified court documents, etc)
x Correction, amendment, and registration information  Sign the application/Original signature required
x Download forms
 Include self-addressed stamped envelope
Telephone: 602-364-1300
Apply Online: www.VITALCHEK.com (Refer to website for their current fees)  Correct fee enclosed - https://azdhs.gov/licensing/vital-
records/index.php#local-county
Today's Date # of Certified Copies # of Non-certified Genealogy  Death Purpose of Request Payment Method
Requested copies requested  Fetal Death
PAYMENT INFO

 Stillbirth

Payment Information
Card Number _______ - _______ - _______ - _______ Card Expiration Date /  Visa  MC
Billing Zip Code ______________ CCV# _______

Signature of Cardholder — Must provide photocopy of valid government issued identification if cardholder is not the applicant. Amount to be Charged
$

Date of Death Sex Name on Death Certificate

DEATH CERTIFICATE INFORMATION

 Male  Female First Middle Last

Place of Death — Hospital or Residence  Hospital

 Residence
City County State
 Other

Funeral Home or Donation Facility

Social Security Number Date of Birth Are Copies to be used for Government Claim?
 Yes  No

If Yes, List Claim (SSA, VA, ETC.)

Applicant's Full Name — Printed APPLICANT'S SIGNATURE — REQUIRED

First Middle Last
PERSON REQUESTING

Mailing Address
Street City State Zip

Daytime Telephone Number Email Address

Your Relationship to Person on Certificate — Check One *PROOF of relationship MUST be provided.
 Parent  Relative  Grandparent  Spouse  Gov't Agency  Other  Specify
Documentation must be provided to support eligibility.

Applicable only if no government issued photo ID is available

State of County of
NOTARY AREA

On this day of , 20 before me personally appeared

(name of signer), whose identity was proven to me

Affix Seal/Stamp Here
on the basis of satisfactory evidence to be the person whose name is subscribed to this document, and who

acknowledges that he/she signed the above document.

Notary Signature My Commission Expires

VS-158 (09/18)
 PARTICIPATING OFFICE LOCATIONS
The Bureau of Vital Records does not provide walk-in service for death certificate issuance. Services available at the Bureau of Vital Records
by appointment only are amendments and corrections for deaths that occurred prior to 2008.

For walk-in customer service, please visit your nearest local county vital records office providing walk-in service as listed below.

Please note payment types accepted at various office locations: Cash (C) - in person only, Money Order/Cashier’s Check (MO), Personal
Check (PC), Credit Cards (CC), Debit Cards (DC).

Please visit http://azdhs.gov/vital-records/ or call for the most current fee schedule for each office.

Bureau of Vital Records Gila County Health & Emergency Management Navajo County Public Health
1818 W. Adams St. Office of Vital Records Services District
Phoenix, AZ 85007 5515 S Apache Ave., Ste.100 117 E. Buffalo St.
(602) 364-1300 Globe, AZ 85501 Holbrook, AZ 86025
(C) (MO) (CC) (DC) (928) 402-8811 (928) 524-4750
Mail to: PO Box 6018 (C) (PC) (MO) (CC) (DC) (MO) (CC) (DC)
Phoenix, AZ 85005
Certified Copies of Birth and Death Graham County Health Department Pima County Health Department
Certificates are Available by Mail Only 820 W. Main Vital Records Office
Safford, AZ 85546 3950 S. Country Club Road Ste.100
Apache County Public Health Services District (928) 428-4441 Tucson, AZ 85714
110 East First Street South (C) (MO) (PC) (CC) (DC) (520) 724-7932
St. Johns, AZ 85936 (C) (MO) (CC) (DC)
(928) 337-7668
Greenlee County Health Department
(MO) (CC) (DC) Pinal County Health Department
Office of Vital Registration
Mail to: PO Box 697 36235 N. Gantzel Rd.
253 5th St.
St. Johns, AZ 85936 San Tan Valley, AZ 85142
Clifton, AZ 85533
(520) 866-4670 / 1-800-231-8499
Cochise County Health and Social Services (928) 865-2601
(C) (MO) (CC) (DC)
Office of Vital Records (C)(MO)
Sierra Vista Office Mail to: PO Box 936 Pinal County Health Department
4115 E. Foothills Dr. Clifton, AZ 85533 41600 West Smith-Enke Rd.
Sierra Vista, AZ 85635 La Paz County Vital Records Office Bldg. 15
(520) 803-3925 and 1112 Joshua Ave, Ste. 206 Maricopa, AZ 85138
(520) 432-9406 Parker, AZ 85344 (520) 866-4621 / 1-800-231-8499
(C) (MO) (CC) (DC) (928) 669-1100 (C) (MO) (CC) (DC)
(C) (MO) (PC) (CC) (DC)
Douglas Office Pinal County Health Department
1012 North G Ave. Ste.101 Maricopa County Florence - Mail Only
Douglas, AZ 85607 Office of Vital Registration P.O. Box 2945
(520) 805-5600 Central Valley Office Florence, AZ 85132
(C) (MO) (CC) (DC) 3221 N. 16th St., Ste.100 (520) 866-7318 / 1-800-231-8499
Phoenix, AZ 85016 (C) (MO) (CC) (DC)
Bisbee Office (602) 506-6805
1415 Melody Lane, Building A (C) (MO) (CC) (DC) Pinal County Health Department
Bisbee, AZ 85603 1729 N. Trekell Rd. Ste.120
(520) 432-9411 North Valley Office Casa Grande, AZ 85122
(C) (MO) (CC) (DC) 2423 W. Dunlap Ave., Ste.110 (520) 866-7447 / 1-800-231-8499
Phoenix, AZ 85021 (C) (MO) (CC) (DC)
Benson Office (602) 506-6805
126 W. 5th Street (C) (MO) (CC) (DC) Santa Cruz County Health Services
2150 N. Congress Dr. Ste.115
Benson, AZ 85602
East Valley Office Nogales, AZ 85621
(520) 585-8200
4419 E. Main St., Ste.105 (520) 375-7900
(C) (MO) (CC) (DC)
Mesa, AZ 85205 (MO) (CC) (DC)
(602) 506-6805
Wilcox Office Yavapai County Health Department
(C) (MO) (CC) (DC)
450 S. Haskell Ave. 1090 Commerce Dr.
Wilcox, AZ 85643 West Valley Office Prescott, AZ 86305
(520) 384-7100 1850 N 95th Ave., Ste.182 (928) 771-3125
(C) (MO) (CC) (DC) Phoenix, AZ 85037 (C) (MO) (PC) (CC/DC)
All sites offer same day service (602) 506-6805 Certified Copies of Birth Certificates and
Please send any mail requests to the Sierra Vista or (C) (MO) (CC) (DC) Death Certificates are Available by Mail Only
Bisbee locations only. For all Mail: PO Box 2111
Phoenix, AZ 85001 Yuma County Health Services
Coconino County Health and Human Services Vital Records Department
2625 N. King St. Mohave County Public Health 2200 W. 28th St.
Flagstaff, AZ 86004 County Administration Building Drop Box in lobby Yuma, AZ 85364
(928) 679-7272 700 W. Beale St. (928) 317-4530
(C) (MO) (PC) (CC) Kingman, AZ 86401 (C) (MO)
Mail to: PO Box 7000
Coconino County Health and Human Services Kingman, AZ 86402
4402 E. Huntington Dr. (928) 753-0748
Flagstaff, AZ 86004 (C) (MO) (CC) (DC)
(928) 679-7272 Certified Copies of Birth Certificates are Available by
(MO) (PC) (CC) Mail Only or Drop Box
Certified Copies of Death Certificates
are Available by Mail Only
PARTICIPATING OFFICE LOCATION (07/19)