Application for Certified Death Certificate

Fairfield County Health Dept–VS
1550 Sheridan Drive, Suite 100
Lancaster, OH 43130
(740) 652-2800 option 2
NO REFUNDS WILL BE ISSUED

$32/copy (card fees apply)

Applicant information

Applicant
(your name)

Applicant name

Phone
Number

Phone number

Full
Address

Full address

Death Certificate Request – Ohio Deaths Only

Name at death

First

Middle

Last

Date of death (M/D/YY)

If death occurred less than five years ago, see below:

No, I do not need the Social Security Number included on the death certificate.

Yes, I am requesting a copy of the SSN included because I am:

The deceased's current spouse (Must provide ID AND proof of marriage) Lineal descendent — ex. child, grandchild, etc. (Must provide ID AND copy of birth certificate(s)) The deceased's executor, attorney / legal agent, or representative of an investigating government agency / Veteran's service officer / private investigator / accredited member of media (Must provide ID AND paperwork) A funeral director responsible for disposition of the body and acting on behalf of the deceased.

Number of copies requested

Funeral Home Use Only

Permit #

$32 per certified copy (card fees apply). Mail or drop off this application with payment to the address above, or order online at the Vital Statistics page. For guidelines on who may request a death certificate with the SSN showing and the two forms of proof required, see the Vital Statistics page. Birth and death certificates cannot be emailed.