APPLICATION FOR A CERTIFIED COPY— MICHIGAN DEATH RECORD
Michigan Department of Health and Human Services
PART 1 – APPLICANT INFORMATION (PERSON FILLING OUT THIS FORM)
Applicant’s
First Name ____________________________ Middle ____________________ Last ______________________________
Mailing
A
ddress _____________________________________ City _____________________ State _______ Zip _____________
Daytime Phone w/ area code *R
equired ________________________ Email ____________________________________
PART 2 – DEATH INFORMATION (TO LOCATE RECORD ON FILE)
The name of the person on record and year of death are required in order to complete the search. Do not leave these areas
blank. If the month and day of death are unknown, we will search the entire year you provide. If you need additional years
searched, please see Part 5 for fee information.
NAME OF DECEASED
(at time of death) First Middle Last
DATE OF BIRTH
(mm/dd/year)
DATE OF DEATH
(mm/dd/year)
DECEDENT’S
PLACE OF DEATH City County State
DECEDENT’S
SEX Male □ Female □
DECEDENT’S SOCIAL SECURITY NUMBER
___ ___ ___ ¯ ___ ___ ¯ ___ ___ ___ ___
ANY SPELLING VARIATIONS
OF DECEDENT’S NAME
DECEDENT’S PARENT’S NAME
First Middle Last
DECEDENT’S PARENT’S NAME
First Middle Last
DECEDENT’S
PLACE OF BIRTH City County State
PART 3 – PURPOSE OF REQUEST
PART 4 – APPLICANT SIGNATURE (PERSON FILLING OUT THIS FORM)
By signing, I understand I am agreeing to pay for a search of State of Michigan Vital Records. This does not guarantee that
a record will be found. Falsifying an application for a vital record and/or assuming the identity of another person is subject to
criminal penalties. Per MCL 333.2894(b) and 445.65.
Your Signature:
(Must be original in ink, by hand) ______________________________________________________ Date: _______________
PART 5 – PAYMENT Application Fee includes one Certified Copy or a No-Find Letter
Base Fee (Includes one year search)
Must check one
□ Short Form □ Long Form
(without medical info.) (with medical info.)
$34.00 $
Additional Years to Search
(If exact death year is unknown)
Specify Years _____ _____ _____ _____ $12.00 per year $
Additional Certified Copies Specify Quantity ________ $16.00 each $
Expedited “Rush” Processing
Reduces in-office time.
(Does not affect mail time to/from our office)
$12.00 additional $
CHECK or MONEY ORDER made out to the “State of Michigan”
(Request will not be processed if payment is not included in envelope)
Total Amount
Enclosed
$
SEE NEXT PAGE FOR PROCESSING TIMES AND MAILING ADDRESS
REQUESTING A MICHIGAN DEATH RECORD
The Michigan Vital Records Office has records of deaths that occurred in Michigan and were filed with the state since 1867.
Some records were not filed with the state; some records are missing from the pre-1906 files. Death records are not restricted
documents in Michigan. Anyone can request that a search be conducted if the application is completed, signed, and submitted
with the required fee paid.
Short Form versus Long Form – A short form record includes pertinent facts of who is deceased, when and where the death
occurred, but no medical information or manner of death. A long form record includes the full death registration including the
medical conditions reported and other circumstances which led to death.
PROCESSING TIMES FOR MAILED REQUESTS
REGULAR SEARCH
Approximately 4 to 6 weeks of in-office processing time, depending on volume of requests received. Then sent via regular mail.
EXPEDITED “RUSH” SEARCH
Approximately 2 to 3 weeks of in-office processing time, depending on volume of requests received. Then sent via regular mail.
ADDITIONAL INFORMATION: Results are sent USPS First Class Mail, Pre-Paid envelopes will NOT be accepted
If you find that the above processing times do not meet your needs, please visit www.michigan.gov/vitalrecords or call our
Eligibility Unit at 517-335-8666 to speak with a customer service representative about available options.
MAIL APPLICATION (WITH CHECK OR MONEY ORDER)
Vital Records Requests
P.O. Box 30721
Vital Records RUSH
P.O. Box 30721
ALTERNATIVE ORDERING OPTIONS
ONLINE
Visit www.michigan.gov/vitalrecords to place an online order via VitalChek. There is an additional $14.00 processing fee.
There is an optional UPS Air delivery fee of $19.75, Rush processing would also be added , and the record would be
received in approx. 1 to 3 business days.
A credit or debit card is required for payment at the time of ordering online. VitalChek is the ONLY authorized service
provider for online ordering for the State of Michigan Vital Records Office.
PHONE
Call 866-443-9897 to place a phone order via VitalChek. There is an additional $14.00 processing fee.
There is an optional UPS Air delivery fee of $19.75, Rush processing would also be added, and the record would be
received in approx. 1 to 3 business days.
A credit or debit card is required for payment at the time of placing your phone order. VitalChek is the ONLY authorized
service provider for the State of Michigan Vital Records Office.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age,
national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political belief, or disability.
DCH-0569-DX (Rev. 10-23) By Authority of MCL 333.2882(1)(a)(b) and MCL 333.2891(1-4) (8)