application for certified copy of a colorado death

PO Box 660
Eagle, CO 81631
(970) 328-8840
APPLICATION FOR CERTIFIED COPY OF A COLORADO DEATH CERTIFICATE
Colorado has birth records for the entire state since 1900
Same day service is available at the Eagle office Monday through Friday 10 a.m. to 2 p.m. Holidays excluded.
REQUESTOR INFORMATION (Person making the request)
REQUESTOR MUST INCLUDE A COPY OF HIS/HER IDENTIFICATION - Driver’s License, State ID or
Passport. ADDITIONAL information might be necessary to establish relationship to deceased
___________
____________________________/________
Full Name
Mailing Address: _________________________
Relationship to Registrant:
____________________________________
Signature
Phone #:
_
Reason for request: ___
_________ _____
REGISTRANT (INFORMATION ABOUT PERSON WHOSE DEATH CERTIFICATE IS BEING REQUESTED)
FULL NAME OF DECEASED:
First______________________________ Middle ______________________ Last______________________________
Date of Death: Month __ __ Day __ __ Year __ __
Place of Death: City _________________ County _EAGLE___
Eagle County provides death certificates for deaths occurred in Eagle County ONLY. If the registrant’s death occurred in
another county please contact the county of death or the State of Colorado Vital Records Office at (303) 692-2200 or
http://www.cdphe.state.co.us/certs/index.html.
PAYMENT INFORMATION:
Number of Copies ______
$20.00 1ST copy
Certificates requested:
$13.00 each additional copy w/same request
$20.00 FedEx Standard Overnight:
$13.00 each certificate exchanged
$0.50 Credit Card Convenience Fee:
Payment Method: make CHECKS payable to EAGLE COUNTY
Total:
__________
__
_
__
__
__________
FOR OFFICE USE ONLY ****************************************FOR OFFICE USE ONLY
Check/Money Order #_
Credit Card # ____________
__ Cash __
_ MasterCard _
_______________ Exp __
Payment RC’D by __________________
_ Visa_
_
__
Security Code _________
Issue Date _____________
Certificate # __________________________ _______________________
Issued By___________________
PO Box 660
Eagle, CO 81631
(970) 328-8840
APPLICATION FOR CERTIFIED COPY OF A COLORADO DEATH CERTIFICATE
Colorado has birth records for the entire state since 1900
Servicio del mismo día es disponible en la oficina de Eagle de lunes a viernes – 10 a.m. A 2 p.m. (excepto en días festivos)
INFORMACIÓN DE LA PERSONA SOLICITANDO EL CERTIFICADO
El SOLICITANTE NECESITA INCLUIR UNA COPIA DE SU IDENTIFICACIÓN – Licencia para conducir, ID o
Pasaporte. Información ADICIONAL tal vez sea necesaria para establecer su parentesco con el difunto
___________
____________________________/________
Nombre completo
Dirección de correo: ______________________
Relación con el difunto:
____________________________________
Firma
# de teléfono:
_
Razón de la solicitud: ___
_________ _____
REGISTRANTE (INFORMACIÓN ACERCA DE LA PERSONA A QUIEN CORRESPONDE EL CERTIFICADO)
NOMBRE COMPLETO DEL DIFUNTOFULL NAME OF DECEASED:
Primer nombre ____________________ Segundo ___________________ Apellido (s)___________________________
Fecha de defunción: Mes __ __ Día __ __ Año _ __
Lugar de defunción: Ciudad _______________ County _EAGLE_
El condado de Eagle proporciona certificados de defunción que ocurrieron en el condado de Eagle solamente. Si la
muerte del registrante ocurrió en otro condado favor de comunicarse con ese condado o la oficina de registros vitales
del estado de Colorado al (303) 692-2200 o http://www.cdphe.state.co.us/certs/index.html.
INFORMACIÓN DE PAGO:
Número de copias ______
$20.00 1era copia
Cantidad de certificados:
$13.00 por cada copia adicional con la misma solicitud
$20.00 FedEx Standard Overnight:
$13.00 por cada cambio de certificado
$0.50 cobro de tarjeta de crédito:
Método de pago: hacer los CHEQUES a nombre de EAGLE COUNTY
Total:
__________
__
_
__
__
__________
FOR OFFICE USE ONLY ****************************************FOR OFFICE USE ONLY
Check/Money Order #_
Credit Card # ____________
__ Cash __
_ MasterCard _
_______________ Exp __
Payment RC’D by __________________
_ Visa_
_
__
Security Code _________
Issue Date _____________
Certificate # __________________________ _______________________
Issued By___________________