Death Certificate Order Form

Death certificates are available from the Department of Health only for deaths which occurred within the past five years. After five years, the records are transferred to the Vermont State Archives and Records Administration (VSARA).

To order a death certificate from the Department of Health:

• Complete and print the application below.
• Sign and date the application.
• Make check or money order payable to "Vermont Department of Health".
• The fee for certified copies is $10.00 per copy.
• Return the application with your check or money order to the address below. Do NOT mail cash.

Send to:
Vermont Department of Health
Vital Records
P.O. Box 70
Burlington, VT 05402-0070

For more information visit: Obtaining Vital Records

Application for a Certified Copy of a Death Certificate

For office use only ID# CPA# REC#

Number of Copies:
Amount Enclosed $
Name on Death Certificate:
Sex: M F

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Date of Death:
Town or City of Death:
Date of Birth:
State of Birth:
Age at Death:
Name of Spouse:

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Your Name:
Address:
Town:
State:
Zip:
Phone Number:
Your Relationship to person on death certificate

Intended use of certificate

Benefits Settlement of Estate Family History
Other: (specify)

Date: _____________________________

Signature: _____________________________________________________________________

Send to: Vermont Department of Health, Vital Records, PO Box 70, Burlington, VT 05402-0070