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 State Archives and Records Administration.

To order a death certificate from the Department of Health:

• Complete the application below
• Print it on your local printer.
• Sign and date the application
• Return it with your check or money order to the address below.
  Make checks or money orders payable to: Vermont Department of Health. Do NOT mail cash.

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

Fees:
Certified copy: $10.00
Verification: no charge
Record Search: no charge

For more information visit: Obtaining Vital Records

Application for Vital Record Death Certificate

For office use only ID# CPA# REC#

Request for:

Certified Copy Verification Record Search

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