Death Certificate - Vital Records

* Required field

Death Record Information

First Name of Decedent

Middle Name of Decedent

Last Name of Decedent

Date of Death

City of Death

Number of Copies

Type of certified copy you are requesting

	Certified Authorized Copy.
Only specific people are eligible to receive this record. This document will establish the identity of the registrant. Refer to Relationship to Registrant section to see if you are eligible. If not, you must request a Certified Informational Copy.

	Certified Informational Copy.
Everyone is eligible to request this record. This document will be printed with a legend on the face of the document that states: "INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY."

Relationship to Registrant

Check the box that establishes your relationship to the person listed on the certificate.

I am:

	A parent or legal guardian of the registrant (person listed on the certificate).
	A child, grandparent, grandchild, brother or sister, spouse, or registered domestic partner of the registrant.
	A surviving competent adult in the next degrees of kinship not otherwise listed above.
	A party entitled to receive the record as result of a court order.
	A member of a law enforcement agency or other government agency, as provided by law, who is conducting official business.
	An attorney representing the registrant's estate, or any person or agency empowered by statute or appointed by a court to act on behalf of the registrant or the registrant's estate, including conservator of the decedent or decedent's estate.
	Appointed rights in a power of attorney (either Health Care POA or General POA). Where General POA, the principal (person authorizing the other act) must be qualified to receive an authorized certified copy. If the principal is the registrant, then it must be a Health Care POA.
	Any agent or employee of a funeral establishment who acts within the course and scope of his or her employment and who orders certified copies of a death certificate on behalf of an individual specified in paragraphs (1) or (8), inclusive or subdivision (a) of Section 7100 of the Health and Safety Code.
	None of the above.

Document

Sworn Statement

By entering my full name in the space provided below I swear or affirm under penalty of perjury under the laws of the State of California, that I am an authorized person, as defined by the California Health and Safety Code Section 103526 (c), and am eligible to receive an authorized copy of this death certificate.

First Name

Middle Name (optional)

Last Name

The County of Riverside is not responsible for the delivery of mail by the United States Post Office or any other delivery service.