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Death Certificate Form

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WISCONSIN DEATH CERTIFICATE APPLICATION

DEPARTMENT OF HEALTH AND FAMILY SERVICES

DIVISION OF HEALTH CARE FINANCING

HCF 5280 (REV. 04/03)    STATE OF WISCONSIN

CHAPTER 69.21 (1a, (2b), Wis. Stats.

PENALTIES: Any person who willfully and knowingly makes false application for a death certificate is guilty of a Class I felony [a fine of not more than $10,000 or imprisonment of not more than three years and six months, or both, per Chapter 69.24(1), Wisconsin Statutes].

THE FOLLOWING INFORMATION IS ABOUT THE PERSON COMPLETING THIS APPLICATION

YOUR Name (Please Print)

YOUR Daytime Telephone Number

YOUR Street Address

Apt. No.

MAIL TO Address (if different)

Apt. No.

City/State/Zip

City/State/Zip

According to Wisconsin Statute, a CERTIFIED copy of a death certificate is only available to a person with a “Direct and Tangible Interest”. If you do not meet the criteria for boxes A – D, please refer to the information on page 2.

Check one box which indicates YOUR RELATIONSHIP to the PERSON NAMED (decedent) on the death certificate

A. I am a member of the immediate family of the PERSON NAMED on the death certificate. (Only those listed below qualify as immediate family.)

CHECK ONE:

B. I am the legal custodian or guardian of the PERSON NAMED on the death certificate

C. I am a representative authorized, in writing, by one of the aforementioned (A or B). The written authorization must accompany this application

Specify whom you represent.

D. I can demonstrate that the information from the death certificate is necessary for the determination or protection of a personal or property right for myself/ my client/ my agency (includes funeral director, informant and medical certifier named on the record).

Specify Interest.

E. I am a direct descendent of the PERSON NAMED on the death certificate (blood grandchild, great grandchild, etc.). (I may receive an uncertified copy of either the “Fact of Death” certificate or the “Extended Fact of Death” certificate.)

F. Other: Uncertified copy only. Copy will not be valid for legal purposes. (Please refer to the information on page 2.)

Fees

First Copy Fee (includes one copy, if found) Fact of Death or Extended Fact of Death (all pre-2003 deaths) $20.00

Each additional copy of the same certificate, issued at the same time as the first copy.

(post 2002 deaths) Fact of Death Certificate (without cause of death and disposition) ….. X $3.00

(pre 2003 deaths) Extended Fact of Death Certificate (with cause of death and disposition) …… X $3.00

TOTAL $

FULL NAME OF DECEDENT

DECEDENT’S DATE OF DEATH

PLACE OF DEATH * (CITY, VILLAGE, TOWNSHIP)

PLACE OF DEATH (COUNTY)

DECEDENT’S SOCIAL SECURITY NUMBER *

DECEDENT’S AGE/BIRTHDATE *

DECEDENT’S OCCUPATION *

NAME OF DECEDENT’S SPOUSE *

NAMES OF DECEDENT’S PARENTS *

Make certified check or money order payable to: REGISTER OF DEEDS. Send completed form, stamped, self-addressed, business-size envelope and your certified check or money order to: REGISTER OF DEEDS, 400 4TH ST N., LA CROSSE, WI 54601.

I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies of the requested death certificate in accordance with the categories listed above.

SIGNATURE – Applicant (Person Completing Application)

Date Signed

* The fields marked with an asterisk (*) do not have to be completed. The information is helpful, but not required.

OFFICE USE ONLY

WISCONSIN DEATH CERTIFICATE APPLICATION

HFC 5280 (Rev. 04/03)    Page 2

What is the difference between a “certified” and an “uncertified” copy of a death certificate?

A CERTIFIED COPY of a death certificate issued by our office will have a raised seal, will show the signature of the State Registrar, and will be printed on security paper. A certified copy may be required to settle an estate or to claim insurance benefits.

State law restricts who may obtain a certified copy of a death certificate. A certified copy can only be issued to the following people:

o An immediate family member (spouse, child, parent, sibling, or grandparent of the decedent);

o A person authorized in writing by one of the above (The written authorization must accompany the request and the relationship of the authorizing party to the decedent must be clearly explained.); or

o A person who can demonstrate that the death certificate is required to determine or to protect a personal or property right.

If you meet one of the above criteria, you may receive a certified copy of the death certificate.

o For pre-2003 death certificates, a certified copy will automatically include cause of death and disposition information.

o For 2003 and later death certificates, you must specify if you want a “Fact of Death” certificate (which does not include cause of death and disposition information) or if you require the “Extended Fact of Death” certificate (which includes cause of death and disposition information).

An UNCERTIFIED COPY of a death certificate will not be acceptable for legal purposes, such as claiming insurance benefits.

o For pre-2003 death certificates, an uncertified Copy of a death certificate will contain the same information as a certified copy.

o For 2003 and later death certificates, only persons named in the above list and direct descendants of the decedent may have access to information in the “Extended Fact of Death” certificate (which includes cause of death and disposition information).

2. Identification of Applicant

What identification is required when applying for a certified or uncertified copy of a birth certificate?

A current valid photo ID (e.g., Wisconsin Driver’s License, Wisconsin State Identification Card, passport, Military Identification Card) is required when applying in person.

A photocopy of the applicant’s current valid photo ID must accompany all mail applications.

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What the Death Certificate Form Is and why it matters

The Death Certificate Form is an official vital-record document created to register a person’s death with state or local vital records offices. It records essential facts including the decedent’s full legal name, date and place of death, cause of death, demographic details, and the certifying physician or medical examiner. Copies of the certificate establish legal proof of death for estate administration, insurance claims, closing financial accounts, benefit enrollment, and public health reporting. Funeral directors typically file the primary record with the state; certified copies are issued to authorized requesters.

Why the Death Certificate Form is needed

A correctly completed Death Certificate Form establishes legal status, triggers probate and insurance processes, and supports statutory reporting obligations to public health authorities. Accurate records reduce delays in claims, estate settlement, and benefits access while meeting state vital-records requirements.

Why the Death Certificate Form is needed

Who interacts with the Death Certificate Form

The Death Certificate Form involves several distinct parties during creation, filing, and subsequent use.

  • Funeral directors and mortuary staff who prepare and submit the primary record to the state vital records office.
  • Certifying clinicians such as physicians, coroners, or medical examiners who provide cause-of-death information and sign the certificate.
  • Family members, personal representatives, insurance companies, and government agencies who request certified copies to complete legal and financial tasks.

Roles vary by state; verify who may request certified copies and the identity verification required by the issuing authority.

Core sections found on a professional Death Certificate Form

Most state death certificates share a consistent structure that collects identity, event, certification, and administrative details required by public health and legal systems.

Decedent Identity

Full legal name, date of birth, Social Security number, race/ethnicity, and usual residence details required for unique identification.

Death Event

Date and time of death, place of death (facility, home, public place), and location details used for jurisdictional reporting.

Cause of Death

Immediate cause, underlying cause, and contributing conditions provided by the certifying clinician or medical examiner.

Certifier Information

Name, title, license number, and signature of the physician, coroner, or medical examiner who attests to cause and time of death.

Funeral Director Block

Funeral home name, license number, and contact information used to file the record and request certified copies.

Administrative Codes

Registration numbers, filing county, and local public-health codes used to track the record in state systems.

Required data elements at a glance

Decedent Name: Full legal name
Date of Death: MM/DD/YYYY format
Place of Death: Facility, city, state
Cause of Death: Immediate and underlying
Certifier: Clinician name and license
Funeral Director: Name and license number

Step-by-step: Completing the Death Certificate Form

Follow these sequential steps to prepare, certify, and file a death certificate accurately.

  • 01
    Collect details: Gather decedent ID, SSN, and residence information.
  • 02
    Record event: Enter date, time, and location of death precisely.
  • 03
    Certify cause: Clinician documents immediate and underlying causes.
  • 04
    File with vital records: Funeral director or authorized filer submits the record.

Setting up an online Death Certificate workflow

Configure digital filing and requester workflows to match your jurisdiction’s submission requirements.

Field Configuration
File format Use PDF/A or PDF per state portal requirements
Field mapping Map form fields to state data schema
Signer authentication Use email, SMS code, or stronger methods
Notifications Route completed copies to requesters automatically

Where to submit the completed Death Certificate Form

Typical submission destinations depend on local rules and who is filing the certificate.

  • State Vital Records: Primary repository for official records
  • Local Health Department: County offices process some filings
  • Funeral Home: Common authorized filer and coordinator
  • Authorized Requesters: Family, legal reps, insurers receive certified copies

Digital signing and eSubmission considerations

Electronic completion and eSubmission depend on state acceptance, signer authentication, and data security controls.

  • Authentication: Email, SMS, or stronger
  • Formats: PDF, PDF/A supported
  • Integrations: Connect to EHRs and record systems

Verify your state vital records office accepts electronically signed and submitted records and follow their format and authentication rules before e-filing.

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Risks and legal consequences of an incorrect form

Incorrect Cause: Delays claims
Name Mismatch: Blocks benefits
Missing Signature: Record rejected
Late Filing: Possible administrative fines
Unauthorized Release: Privacy liability
Altered Document: Criminal exposure

Common preparation errors to avoid

  • Entering nicknames instead of legal names leads to rejected requests or delays for certified copies and benefits.
  • Using vague or non-specific cause-of-death language prevents accurate public-health coding and may require medical examiner follow-up.
  • Failing to include certifier credentials, license number, or signature frequently results in incomplete filings and returned forms.
  • Submitting photocopies rather than certified copies when required by insurers or probate courts can stall claim and estate procedures.

Timing and processing expectations

Timely completion and filing reduce downstream delays; exact processing times and deadlines vary by state and office.

Immediate Notification:

Report death promptly to the funeral director

Filing with Vital Records:

File as soon as paperwork is complete

Certified Copy Requests:

Processing times vary by state

Insurance Deadlines:

Submit copies quickly to avoid claim delays

Probate Triggers:

File during initial estate opening procedures

Frequently asked questions about the Death Certificate Form

Answers to common questions about completing, correcting, and obtaining certified copies of death certificates.


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