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DEATH
COMMONWEALTH OF KENTUCKY
STATE REGISTRAR OF VITAL STATISTICS
APPLICATION FOR A CERTIFIED COPY OF DEATH CERTIFICATE
Certificates of Death that occurred in Kentucky since 1911 are on file in this office
Please Print or Type All Information Required On This Form
DEATH CERTIFICATE INFORMATION
1. Full Name at Death
First
Middle
Last
2. Date of Death
Month
Day
Year
Age Last Birthday
3. Place of Death
Kentucky City or Town
Kentucky County
Name of Hospital (if any)
4. Attending Physicians
Name
First
Middle
Last
5. Funeral Service
Provider
Name of Establishment
Address
Telephone Number
What is your relationship to the person whose certificate is being requested?
_____________________________________________________
Signature and telephone number of the person requesting this certificate:
_____________________________________ ___________________
Signature Telephone
_____________________________________________________________________________________________________
Certificates may also be ordered by the following methods:
Internet: Certificates may be ordered on the internet using a credit card (Visa, MasterCard,
Discover or American Express) or check. An additional charge card fee will apply.
This is in addition to the fee for each certified copy requested. Certificates requested via
internet,
www.vitalchek.com/kentucky-express-birth-certificates.aspx, may be returned by
overnight courier for the cost of the additional shipment fee if that record is available.
Telephone: Orders may be placed by telephone using a credit card (Visa, MasterCard,
Discover or American Express) or check. An additional charge card fee will apply. This is in
addition to the fee for each certified copy requested. Certificates requested via telephone may
be returned by overnight courier for the cost of the additional shipment fee. The telephone
number to place your order is (800) 241-8322, choose option 1.
Mail: Orders are accepted by mail, using a check or money order in U.S. dollars drawn on a
U.S. bank for payment. It can take up to 30 working days to process your request from the
date payment is posted. Mail to Vital Statistics, 275 East Main Street 1E-A, Frankfort, KY
40621. The Office of Vital Statistics telephone number is (502) 564-4212.
Walk-in: You may order a certified copy of the death record by coming to this office. The
office is located at the address above. Orders are accepted for same day issuance from 8:00 AM
until 3:30 PM Monday through Friday.
______________________________________________________________________________________________________________________________
THIS SECTION MUST BE COMPLETE FOR ALL ORDERS
REQUESTORS INFORMATION:
__________________________ NAME
__________________________ MAILING ADDRESS
__________________________
__________________________ CITY, STATE, ZIP CODE
VS-31
(Rev 1/30/2012)
DO NOT WRITE IN THIS SPACE
Volume
Certificate
Year
Date
Searched by
FEES
A fee is to be paid for certified copies or
records, or for a search of the files or records
when no copy is available. The fee for a
certified copy of a death certificate is $6.00
U.S. Additional copies are $6.00 U.S. each.
Make check or money order payable to
“Kentucky State Treasurer.” This fee is non
refundable.
________ Certified Copies @ $6.00 each
How many
Total Amount Enclosed __________