Please type in CAPITAL letters Fax to (512) 331-8230
DEATH CERTIFICATE INFORMATION
Certificate Holders Name
  First name Middle name
Date of Death: Sex
 
City of Death: County of Death:
State of Death: Hospital...........
Relationship: ,,, .:. .Other:
Reason for Request:
Other: .Number of Copies:

SHIPPING AND DELIVERY INFORMATION
Ship to:
  First name Middle name Last name
Shipping Address:
Apartment No:
City: State: Zip:
Daytime Tel:
E-mail:
Number of CopiesDelivery Method:
CREDIT CARD INFORMATION

Name on Credit Card
  First name Middle name Last name
Billing Address:
Apartment No:
City: State: Zip:
Credit Card Number: Expires

Card Holder Signature:_____________________________________ Date:
WARNING:
False application for a Birth Certificate is a punishible offense. For protection of the individual, certificates of vital events
are ONLY available to the indididual listed on the certificate or to a parent..

Requestor Signature:_____________________________________ Date: Needed by :

I authorize US Vital Documents or their represantative to obtain this death certificate for me.
Choose One:
*You must list a physical street address (no APO's, FPO's, or P.O. Boxes)


Fax to (512) 331-4354
Rush Delivery*: Regular Delivery:
Our Fee: $45.00
State Fees: $25.00 - $35.00
Our Fee $25.00
State Fee: $8.00 - $10.00
*(includes FEDEX Overnight charges)
* You will receive three separate charges on your credit card
*You Must also fax a copy of your drivers license or state issued id.
Number of copies
All Sales Final, No Debit Cards Accepted.Process times may vary based on workload of state agencies.
I understand that US Vital Documents is not responsible for any service
performed by any overnight courier service.