Death Certificate Request (PDF)

STATE OF CONNECTICUT 
DEPARTMENT OF PUBLIC HEALTH (DPH) 
Request for a Certified Copy of a Death Certificate from the Town of Death Vital Records Office
VS-39DTW 
  Revised:   9/6/2011 
        PLEASE PRINT              
  DO NOT MAIL CASH OR PERSONAL CHECKS 
Full Name of Deceased:  (First, Middle, Last): 
  SEX 
  M 
  F
Date of Death: (Month/Day/Yr): *
Town of Death: 
Date of Birth (Month/Day/Yr):
Place of Birth   (Town, State or Country): 
Father’s Name: 
Mother’s Name: 
If Married, Spouse’s Name: 
Person Requesting the Death Certificate: 
Name:       ______________________________________________________________________________________________________ 
First
Middle
Last Name
Address:   _____________________________________________________________________________________________________ 
Number 
   Street 
  Town/City       
State 
Zip Code 
(______)________________       __________________________ 
Relationship To Deceased: **  ___________________________
Telephone No. 
E-Mail Address (optional)
_______________________________________________ 
Signature:  X__________________________________________ 
    Intended Use of Certified Copy (e.g. Benefits, Genealogy, etc.) 
** Note: Per CT law (C.G.S. §7-51A), for deaths occurring on or after July 1, 1997, only the Funeral Director and the surviving spouse
or next of kin may obtain a copy of the death certificate with the decedent’s Social Security number listed on the death certificate.  All 
other requesters will receive a certified copy without the decedent’s Social Security number.   
If eligible, do you want the decedent’s Social Security number on the copy of the certificate?   No: _____ Yes: _______ 
If “Yes,” there is no need for the spouse or next of kin to submit a copy of their ID or proof of relationship to the deceased.  
One Time Fee Waiver for A Copy of a Veteran’s Death Certificate: 
Effective 10/1/2011, CT law (C.G .S. §7-74 (c)) allows the spouse, child or parent of a deceased veteran to obtain one (1) free copy of 
the deceased’s death certificate provided the requester presents a copy of their valid Government issued photo I.D. and proof of 
their relationship to the deceased.   Examples o f proof of relationship include a marriage certificate for a spouse, one ’s own birth 
certificate, if a child of the deceased, or the deceased’s birth certificate, if a parent of the deceased.   
Are you requesting the one time waiver of the $20.00 fee and enclosing required documentation?  No: ____ Yes  ____ 
The fee will be waived only if the request includes the required valid ID, proof of relationship to the veteran, and if the veteran status  
is indicated on the death certificate.    
The fee for a copy of a Death Certificate from the State or Town is $ 20.00 per copy.  Check or Money 
Order is accepted.  
# of Copies Requested:   ______  
  Amount Enclosed:  $  _______      
Fee Waiver Request:  ________  
Please mail this request with a Check or Money Order made payable to the Waterford Town 
Clerk. 
For town contact information, refer to the Town Vital Records Directory on the Department of Public 
Health’s Vital Records website at www.ct.gov/dph. 
* Note: Copies of death or marriage certificates for events that occurred less than 4 months prior to the date of the request should be sent
to the Vital Records office in the town of the event.   Refer to our website at www.ct.gov/dph for town contact information.