Death Certificate Order Form
			Complete this application, then fax to Express Birth Records toll-free at 877-684-5852 .   Customer Service: 888-803-1118.
			Required fields are noted with (R)             Please print with dark ink!
	Decedent's Name:(R)  First___________________Middle___________________Last__________________________                                                                     ( If no middle name, or unknown, then leave blank.) Gender: (R)   Male ___        Female___           Date of Death: (R)  Month _______  Day _____  Year ________                       Funeral Home / Hospital:  __________________________________ (if available) City: (R) ________________________________                        State: (R) ______________ Relationship to Certificate Holder: (R)  _____________________________  (self, mother, father, etc.) Certificate Number (If available): ____________      Reason For Request:(R) __________________________________  ( benefits, personal, etc.)                                                                                                                                    Requestor's  Date Of Birth: (R) Month ______  Day _____  Year ______       Last 4 digits of  Requestor's  Social  Security #: (R) _____________   ****  (Records coming from Colorado and Kansas require the full social security number) ****
		***Method of Shipping: (R)       Regular Mail ___   Federal Express___  (please check a shipping method) "Ship to" Name: (R) (Person ordering Certificate) __________________________________________________ "Ship to" Address: (R)  (street, apt. #) _________________________________________________ City: (R) ________________________________  State: (R) ________________Zip Code: (R) ______________ Contact Number: (R) (           ) __________ - _________________ ( in case we need to reach you ) Payment Method: (R)       Visa___     Mastercard___     American Express___    Discover ___ Credit Card Number: (R)   ___________________________________  Expiration Date:(R) ________________ Card Verification Code (usually last 3 numbers on back of credit card): (R) _______ Name on Card ( Card Holder ): (R) _________________________________________ Credit Card  Billing Address: (R)  (street, apt. #) _________________________________________________ City: (R) ________________________________  State: (R) ________________Zip Code: (R) ______________ Applicant's Signature:(R) ________________________________________  Date:(R)  ____/____/_____