PUBLIC HEALTH Vital Records
Application for Certified Copy of Death Certificate
www.BoulderCountyDeathCertificates.org
Make checks or money orders payable and send to:
Boulder County Public Health Boulder County Public Health
3450 Broadway 515 Coffman Suite 200
Boulder, CO 80304 Longmont, CO 80501
303-441-1100 303-678-6166
Requirements:
• This request must be completed in full.
Number of Copies VA Total Fee _
FEE: $20.00 for one copy $13.00 for each additional copy of
same record when ordered at the same time.
Exchange $13.00 each
Cost of Legal death certificate $20
(all legal and no medical information
)
Cost of Verification of death $20
(limited legal information and no medical information)
•
Enclose a copy of a current driver’s license, passport or State identification
•
(See below for complete list of approved primary and secondary ID’s)
•
Enclose appropriate fees
•
Person requesting to receive a Death certificate must sign below
Information about person whose death certificate is being requested
Full name of the
deceased
First
Middle
Last
Date of death
Month
Day
Year
Age at death
Reason for request
Place of death
City
County
State
COLORADO
^ I consent for communication via e-mail
Pursuant to Colorado Revised Statues §25-2-117 and as defined by Colorado Board of Health Rules and Regulations, applicant must have a direct and tangible interest in the record requested. The
penalties for obtaining a record under false pretenses include a fine of not more than $1,000.00, or imprisonment in the county jail for not more than one year, or both such fine and imprisonment (CRS
§25-2-118).
PLEASE RETURN THIS APPLICATION WITH A COPY OF YOUR DRIVER'S LICENSE, STATE ID, PASSPORT, OR OTHER APPROVED IDENTIFICATION.
Print Name of Person
Making Request
First
Middle
Last
Address
City
State
Zip Code
Daytime Phone
Pursuant to Colorado Revised Statutes, 1982, 25-2-118 and as defined by Colorado Board of Health Rules and Regulations, applicant must have a direct and tangible interest in the record
requested. The penalties for obtaining a record under false pretenses include a fine of not more than $1,000.00, or imprisonment in the county jail for not more than one year or both such fine and
imprisonment (CRS 25-2-118).
by signing below, I have read and understood that there are penalties for obtaining a record under false pretenses)
Relationship to Registrant*
(person named on
certificate)
Today’s Date
*Please note that proof of relationship (e.g. marriage certificates, birth certificates, court orders, release of information, etc.) is required.
Legal representatives of any of the above*
Genealogists representing family members*
Approved Identity Verification list
We cannot accept
the following:
• Birth Certificate Issued by a
Foreign Governments
• City and County Detention
Center ID Cards
•
IRS-ITIN Card or Letter
• Matricula Consular Card
• Medicaid Cards (Excluding
Colorado)
• Novelty Cards
• Souvenir Birth Certificates
• Temporary Driver’s License
or Temporary State ID Cards
from other States
• Tribal ID Cards
• Undated Documents
• Veteran’s Universal Access
ID Cards
Primary Listing (at least one)
OR
Secondary Listing (must have at least two)
•
Alien Registration Receipt or Permanent Resident Card
(INS I-151 or I-551)
•
Certificate of US Citizenship (Form N-560- N-561)
•
City of Denver/Denver County Jail Temporary Inmate ID
•
County OF Pueblo Jail Inmate Temporary ID
•
CO Department of Corrections ID Card
•
CO Temporary Driver’s License; MUST be within 30 days
period, MUST be issued by Colorado DMV
•
Department of Human Services Youth Corrections ID
•
Employment Authorization Card (I-766)
•
Foreign Passport
•
Government Work ID
•
Job Corps ID Card
•
Non-U.S. or International Driving License or Photo ID Card
non-driver’s license (issued by Country)
•
School, University, or College ID card (must be current)
•
Temporary Resident Card (I-688, I668A, or I-688B)
•
US B1/B2 Visa Card PLUS I-94
•
US Certificate of Naturalization N-550- N-/570
•
US Citizenship ID Card (I-197)
•
US Merchant Mariner Card
•
US Military Identification Card
•
US Passport or Card
•
US State or Territory Photo Driver License or Photo ID Card
•
Acknowledgement of
Paternity document
•
US Birth certificate of
the
applicant
•
Court order for
adoption or name
change
•
Craft or trade license
•
DD-214
•
Divorce Decree (U.S. only)
•
Colorado Gaming License
•
Hospital Birth Worksheet (within 6 months of birth)
•
Colorado Hunting or Fishing license
•
Medicaid Card/Health First Colorado (Colorado Only)
•
Non-U.S. or International Driving License or Photo ID card -non-
driver’s license (Issued by State/Province)
•
Marriage License / Certificate
(U.S. only)
•
Medicare Card
•
Mexican Voter Registration Card
•
Motor Vehicle Registration or Title (must be current - U.S. only)
•
Pilot License
•
State, Territorial, or Federal prison ID or Correction Card
•
Social Security Card
•
US Selective Service Card/Letter
•
Weapon or gun permit (U.S. only)
•
Work ID, Paycheck Stub, Pay Statement, or W-2 (last tax year)