VS-31
(Rev 1/30/2012)
COMMONWEALTH OF KENTUCKY
STATE REGISTRAR OF VITAL STATISTICS
DEATH APPLICATION FOR A CERTIFIED COPY OF DEATH CERTIFICATE
Certificates of Death that occurred in Kentucky since 1911 are on file in this office
Please Print or Type All Information Required On This Form
DEATH CERTIFICATE INFORMATION
1. Full Name at Death First Middle Last
2. Date of Death Month Day Year Age Last Birthday
3. Place of Death Kentucky City or Town Kentucky County Name of Hospital (if any)
4. Attending Physicians First Middle Last
Name
5. Funeral Service Name of Establishment Address Telephone Number
Provider
DO NOT WRITE IN THIS SPACE
What is your relationship to the person whose certificate is being requested?
_____________________________________________________ Volume
Certificate
Signature and telephone number of the person requesting this certificate: Year
_____________________________________ ___________________
Date
Signature Telephone Searched by
_____________________________________________________________________________________________________
Certificates may also be ordered by the following methods:
Internet: Certificates may be ordered on the internet using a credit card (Visa, MasterCard,
FEES
Discover or American Express) or check. An additional charge card fee will apply. A fee is to be paid for certified copies or
This is in addition to the fee for each certified copy requested. Certificates requested via records, or for a search of the files or records
internet, [Link]/[Link], may be returned by when no copy is available. The fee for a
overnight courier for the cost of the additional shipment fee if that record is available. certified copy of a death certificate is $6.00
Telephone: Orders may be placed by telephone using a credit card (Visa, MasterCard, U.S. Additional copies are $6.00 U.S. each.
Discover or American Express) or check. An additional charge card fee will apply. This is in Make check or money order payable to
addition to the fee for each certified copy requested. Certificates requested via telephone may “Kentucky State Treasurer.” This fee is non
be returned by overnight courier for the cost of the additional shipment fee. The telephone refundable.
number to place your order is (800) 241-8322, choose option 1.
Mail: Orders are accepted by mail, using a check or money order in U.S. dollars drawn on a ________ Certified Copies @ $6.00 each
U.S. bank for payment. It can take up to 30 working days to process your request from the How many
date payment is posted. Mail to Vital Statistics, 275 East Main Street 1E-A, Frankfort, KY
40621. The Office of Vital Statistics telephone number is (502) 564-4212.
Total Amount Enclosed __________
Walk-in: You may order a certified copy of the death record by coming to this office. The
office is located at the address above. Orders are accepted for same day issuance from 8:00 AM
until 3:30 PM Monday through Friday.
______________________________________________________________________________________________________________________________
THIS SECTION MUST BE COMPLETE FOR ALL ORDERS
REQUESTORS INFORMATION:
__________________________ NAME
__________________________ MAILING ADDRESS
__________________________
__________________________ CITY, STATE, ZIP CODE