DEATH Application for Certified Copy of Maryland Death Record DEATH
Maryland Department of Health ● Division of Vital Records
By my signature below, I state that I am the person I represent myself to be herein, and I affirm that the information submitted on this form is
complete and accurate and submitted subject to the criminal penalties set forth at Maryland Code Annotated, Health-General Section 4-227.
Signature of person making request: __________________________________________________
Date of Application: ______________________________________________________________
PRINT or TYPE your name & CURRENT address.
Your relationship to the person
Name: _______________________________________________________ named on the Certificate: _____________________________
Address: ________________________________________________________________________________________________________
City: _______________________________________________________________ State: ____________________ Zip: _____________
Daytime phone number: (______) ________- ___________ E-mail Address: __________________________________________
PHOTO ID REQUIRED: The individual requesting the record should submit a legible copy of his/her VALID GOVERNMENT-
ISSUED PHOTO ID with completed application. (Examples: State issued driver’s license or non-driver photo ID with requestor’s
current address; passport). If you do not have a Government-issued photo ID, read and sign the following statement: I declare that I
do not have a government-issued photo ID and that I am presenting the attached two documents that include my name and current
address as proof of identification. (Note: These documents must include two of the following: Utility bill, car registration form, pay
stub, bank statement, copy of income tax return/W-2 form, letter from a government agency requesting a vital record, or lease/rental
agreement. Please submit photocopies since these documents will not be returned to you. If you do not have a Government-issued photo
ID, the certificate(s) will be mailed to the address listed on the documents that you present.)
ENTITLEMENT DOCUMENTATION REQUIRED: The requester must present documentation such as a birth or marriage
certificate for a surviving relative, a letter of administration or authorization of release from a surviving relative or a court order or
other business need documentation. For further information, visit the Vital Statistics Administration website at
www.health.maryland.gov/vsa.
Signature: ______________________________________________________________________
Name of Decedent: _________________________________________________________________________________________
Date of Death: __________________________ Age at death: _________ Sex: □ Female □ Male
(Month/Day/Year)
Place of Death: ________________________ Name of funeral home: ____________________________________________
(County or Baltimore City)
Reason for requesting certificate: ____________________________________________________________________
ORDER INFORMATION
There is a non–refundable fee of $10 for the first copy of a death certificate purchased in a single
transaction.* There is a fee of $12 for each additional copy of the same certificate purchased in the same
transaction. Send check or money order. Do not send cash when applying by mail. When paying by
check, you must include a copy of your driver’s license or other government-issued photo ID that lists your
current address, or other acceptable ID as noted above.
When ordering by mail, send completed application, legible copy of ID, documentation of entitlement, a
self-addressed, stamped envelope, and check or money order payable to the DIVISION OF VITAL
RECORDS to the Division of Vital Records, P.O. Box 68760, Baltimore, Maryland 21215-0036.
You may also apply for a death record in person or online. For further information, visit the Vital Statistics
Administration website at www.health.maryland.gov/vsa.
*There is no fee for: (a) A copy of a certificate of a current or former armed forces member that is requested by the member; or (b) A copy
of a certificate of a current or former armed forces member or of a surviving spouse or child of the member, if the copy will be used in
connection with a claim for a dependent or beneficiary of the member. Proof of service in the armed forces must be provided.
To obtain death records for genealogical purposes, contact the Maryland State Archives in Annapolis (telephone number 410-260-6400).
Number of
certificates
requested
Fee for first
paid copy*
$10
Fee for each
additional copy
$12
Amount
enclosed
Rev. 10/21
NOTE: A copy of a death certificate may only be issued to applicants who have a direct and tangible interest in the content of the
record as described in Code of Maryland Regulations (COMAR) 10.03.08. This includes surviving relatives, an authorized
representative, beneficiaries, and those with a business need or court order.
For Issuing Office Only
Photo ID Mailed
