Carter County Court House

214 Park Street / PO BOX 315

Ekalaka, MONTANA 59324-0315

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 U.S. funds)

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Carter County Court House

214 Park Street / PO BOX 315

Ekalaka, MONTANA 59324-0315

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 _______________________________