Application for Search of Death Record

ELIGIBILITY TO OBTAIN AN ILLINOIS DEATH RECORD

Before a request for an uncertified or certified copy can be considered, you must specify your eligibility to obtain it.

IlCS410/535/25/4(d) states that copies of death or fetal death records may be issued upon:

• The specific written request for an uncertified or certified copy by a person, or his duly authorized agent, having

a genealogical, (record must be more than 20 years old), personal or property right interest in the record.

If you are requesting a death certificate as the duly authorized agent or legal representative, please know that you

must provide proof.

• We will review the request if you have a written document naming you as one of the following: a licensed attorney

acting on behalf of a decedent or his/her estate; an agent authorized by power of attorney; a court-appointed

personal representative, executor/administrator; or an agent with expressed, notarized authorization.

If you are requesting a death certificate as someone claiming a legal, personal or property interest, please know that

you must provide proof.

• We will review the request if you have a written document demonstrating that you have a personal or property

interest at stake, such as a will naming you, a letter on a firm’s letterhead or a file-stamped copy of a complaint

at law.

If you are eligible, please indicate on the front of this application your relationship to the deceased person, whose record

you are requesting, the intended use of the copy and proof.

ACCEPTABLE PROOF OF ID

A NON-EXPIRED, GOVERNMENT ISSUED PHOTO ID, such as a driver's license. If you have an extension sticker on

your license, submit a copy of both sides of the license. If you do not have a driver's license, a photo ID Card issued

by the Department of Motor Vehicles can be provided.

If your driver's license or ID Card is expired or not available, you must submit TWO (2) pieces of documentation with

your name on them. In addition to your name, one piece must also have your current address on it to prove your identity.

ONE piece of documentation can be a bill or other USPS mail; the SECOND must be one of the items listed below:

• Medical/car insurance card • Car registration paperwork

• Credit card statement • Bank statement

• Paycheck stub with imprinted information • Public assistance card

• Voter’s registration card • Active duty military ID w/ issued and expiration dates

SOCIAL SECURITY CARDS ARE NOT ACCEPTABLE

Matrícula Consular card issued after October 2006 is acceptable on its own. However, if issued prior to

October 2006, we need ONE additional type of documentation showing current address as noted above. If

you do not have any of the items listed above, please submit a copy of a current utility bill (electricity, cellular

phone, water, etc.) showing your name and current address.

If you are currently incarcerated, you can submit a dated copy of your prison intake/offender summary sheet

containing your photo. If you have been released from prison within the last six months, a copy of the release

papers along with the prison photo ID will be accepted.

If you are writing from a state or federal agency, you can submit a copy of your photo work badge with issued

and expiration dates.

State of Illinois

Illinois Department of Public Health

FULL NAME OF First Middle Last (legal name at time of death)

DECEASED

PLACE OF Hospital City or Town County State

DEATH

DATE OF Month Day Year SEX RACE OCCUPATION SOCIAL SECURITY NUMBER

DEATH

DATE LAST KNOWN Month Day Year LAST KNOWN STATUS (married, divorced,

TO BE ALIVE ADDRESS civil union)

DATE OF Month Day Year BIRTH PLACE (City and State) NAME OF SPOUSE OR CIVIL UNION PARTNER

BIRTH

NAME OF FATHER/CO-PARENT OF DECEASED NAME OF MOTHER/CO-PARENT OF DECEASED

PRIOR TO FIRST MARRIAGE/CIVIL UNION PRIOR TO FIRST MARRIAGE/CIVIL UNION

PLEASE NOTE: The state of Illinois, Division of Vital Records, in Springfield, issues certified death certificates from its electronic

Illinois Vital Registration System (IVRS), if the death occurred from 2008 forward. Any death record, from 2007 or before, is issued

from the original paper record or from microfilm. As a result, these certificates may look slightly different, according to the year of

the event, but they are all certified copies and suitable for all legal purposes.

__________________________________________________ __________________________________________________

YOUR RELATIONSHIP TO DECEASED INTENDED USE OF DOCUMENT

(SEE OTHER SIDE FOR ACCEPTABLE PROOF OF RELATIONSHIP AND INTENDED USE)

Please indicate below the type and number of copies requested and return this form with the proper fee and a legible copy of your

non-expired government issued photo ID. If an extension sticker is affixed to the back of the ID, both sides of the photo ID must

be submitted.

(SEE OTHER SIDE FOR ACCEPTABLE PROOF OF ID)

DO NOT SEND CASH – Make check or money order payable to: ILLINOIS DEPARTMENT OF PUBLIC HEALTH

CERTIFIED

$19 first copy $4 each additional copy

Amount enclosed $___________________for

_________total copies

GENEALOGICAL (uncertified) (records older than 20 years)

$10 first copy $2 each additional copy

Amount enclosed $___________________for

_________total copies

NOTE: Death Certificates are confidential records and copies can only be issued to persons entitled to receive them.

The application must indicate the requestor's relationship to the person and the intended use of the document. (SEE OTHER SIDE)

MAIL TO: Illinois Department of Public Health, Division of Vital Records, 925 E. Ridgely Ave., Springfield, IL 62702-2737

For more information - www.idph.state.il.us/vitalrecords/index.htm

VR 280 (Rev. 5/16)

Printed by Authority of the State of Illinois P.O.#1416154 10M 4/16 IOCI 16-577

INDIVIDUAL REQUESTING COPIES

PRINT NAME_________________________________________

STREET ADDRESS ___________________________________

CITY____________________ STATE ____ ZIP __________

SIGNATURE _________________________________________

MAIL RECORD(S) TO: (If other than applicant)

NAME ______________________________________________

AGENCY ____________________________________________

STREET ADDRESS ___________________________________

CITY____________________ STATE ____ ZIP __________

State of Illinois

Illinois Department of Public Health

Application for Search of Death Record Files

The state began recording death records on January 1, 1916.