Phone: 1-406-775-8749/Fax: 1-406-775-8750
PLEASE READ THESE INSTRUCTIONS CAREFULLY
WHO CAN ORDER A DEATH CERTIFICATE?
Complete copies of a certified death certificate within two years of the date of death can only be issued to the following: parent, spouse, child (must provide proof of relationship/legal need), legal guardian (must provide proof of guardianship), authorized representative (must provide proof) or those who provide documentation showing it is needed for determination or protection of the individuals personal or property rights, proof of relationship, guardianship, or authorization is required before they may obtain certify copy of a death record. Other requestor may receive a copy of a death certificate, however, because of HIPPA restrictions the cause of death information will be protected for two years. After two years they may receive a complete “Informational Only” copy upon producing identification and demonstrating a need.
IDENTIFICATION IS REQUIRED
The person signing the request must provide an enlarged legible photocopy of both sides of their valid driver’s license or other legal picture identification with a signature or the requestor must have this application notarized.
SEE LIST OF ACCEPTABLE IDENTIFICATION
IMPORTANT: If the identification requirement is
NOT met or if the application is incomplete, your request will be returned and
significant delays in processing your order may occur. FEE (All fees must be
• CERTIFIED COPIES OF A DEATH CERTIFICATE cost
$3.00 for the first copy, (non-refundable)
Informational Copies of a Death Certificate costs $.50.
Searches cost $.50 for each year
Phone: 1-406-775-8749/Fax: 1-406-775-8750
Please complete the following information.
Decedent’s Name: ______________________________________________
Date of Death (We need a date to begin searching if date is unknown): _____________
Date of Birth: ___________________________
Place of Death: ___________________________________________
Place of Birth: ________________________________________
Parents Names: ___________________________________________________
Occupation: _____________________________________
Spouse’s Name: _____________________________________________
Number of Copies _______________
Type of record needed? Certified __________Not Certified _________
Reason record is needed ___________________________________________________
Mailing or Delivery Address:
Name: __________________________________
Address:
City, State, Zip: _____________________________
Daytime Telephone Number:_________________________
Signature of Applicant: _____________________________________________
Relationship: ______________________________
Notary
_(For use if needed)________________________________________________
_____________________________personally appeared before me and whose identity I proved on the basis of satisfactory evidence to be the signer of the above instrument.
Subscribed and sworn to before me on this day of ________________ 20____
Signature:
_________________________________________________
Printed Name: _____________________________________________
SEAL Notary Public in and for the State of ___________________________
Residing at _______________My commission expires____________
NOTICE: STATE LAW PROVIDES PENALTIES FOR PERSONS
WHO WILLFULLY AND KNOWINGLY USE OR
ATTEMPT TO USE THIS CERTIFICATE FOR ANY PURPOSE OF
DECEPTION. (50-15-114, MCA)
Official Use Only
Date ____________________________________
Rec # ___________________________________
Amount _________________________________
Cert #___________________________________
Ser #____________________________________
Comment _______________________________