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  REQUESTS













Death Certificate Request
State Center for Health Statistics Administration  
For District of Columbia Occurrences Only

Mail-In Form  (Instructions)
1. Name of Deceased:
2. Social Security Number of Deceased: - -
3. Sex:  Male  Female
4. Date of Death: / / (mm/dd/yyyy)
5. Death Certificate No: (if known)
6a. Total number of copies of certificate requested: @ $18.00 each:
6b.(a) Number with cause of death included:       
     (b) Number with cause of death omitted:    
6c.Total Amount Enclosed: $
7.  Relationship to Deceased:  Mother   Father   Spouse
 Other  
8. Signature of Requester: ___________________________
9. Date: ____/_____/________
Make Check/Money Order Payable to: DC Treasurer
Mail Certificate(s) to:
10. Name:
11. Address:
12.City/State/Zip Code
13. Day Phone: (required) 
*Copy of Requester's Photo ID is Required! 
Instructions to be completed:
1. Print, sign, date form and a copy of requester's photo ID
2. Enclose check / money order payable to: DC Treasurer
3. Mail to: Government of the District of Columbia
Department of Health
Vital Records Division
825 North Capitol Street, NE, First Floor
Washington, DC 20002/ Phone: (202) 671-5000

Note: For security reason, please click this button to clear the data you have entered after printing this form.

Death Application Instructions
If record is not located a "Certificate of Search" will be issued and the payment for the search is non-refundable.

The death transcript request form contains 13 questions. A separate copy of the request form should be completed for each person whose death record is being requested. However, multiple copies of a single death record may be requested on the same form.

Items 1-4: Information about the deceased.

Items 5: Information about the record being requested.
Note: Persons entitled to purchase a vital record birth or death certificate included:
  • The registrant
  • An immediate nuclear family member
  • A legal guardian
  • A legal representative
Item 6a: Please indicate the total number of certificates that you are requesting.

Item 6b/a: Please indicate the number of requested copies of certificates on which you wish to have the cause of death included.

Item 6b/b: Please indicate the number of requested copies of certificates on which you wish to have the cause of death omitted.

Item 6c: Please indicate the total amount of money that you are enclosing. This amount should equal the requested number of transcripts multiplied by $18.
If you send your request by mail, please enclose a check or money order
payable to the DC Treasurer.    The cost of either type of transcript is $18.

Item 7: The requester's relationship to the deceased.

Item 8: Please sign your signature once the mail-in form has been completed.

Item 9: Please date the form.

Item 10:-13 Information about the designated recipient of the certificate(s).

After you print and sign your request, click the clear button to erase the data you have entered, mail the form and a copy of your picture ID with your payment to:

Vital Records Division
825 North Capitol Street, NE, First Floor
Washington, DC 20002
(202) 671-5000

If record is not located a "Certificate of Search" will be issued and the payment for the search is non-refundable.