Online Certificate Specialists
What you will need to do is fill out the form below and hit the print button on your browser.Then make a copy of your driver’s license or your state issued identification card (if available) and fax both to us at 800-856-2383 or 713-974-6884. You MUST have a Discover, American Express,Visa or Mastercard number on the form below as this is how the states and our company will charge you for your CertificateThe only states we can not obtain Death Certificates are New York, Arizona, Hawaii, Iowa, Louisiana, Missouri, Nebraska,, New Mexico, Rhode Island, and South Dakota.
Debit cards may be used (must have a Visa or Mastercard logo on Debit card),
PLEASE USE CAPITAL LETTERS ON THE FORM BELOW

Fees:    State Fee: $28 and up +  Our Fee: $45.00

Death Certificate Request
Certificate Holders Name:
...................... ..(First)(Middle)(Last)
Date of Death(day/month/year): Age at time of death
County where death occured City where death occured
Social Security # of Deceased Date of Birth of Deceased
Funeral Director
State where death occured Hospital..... Sex
Father of Deceased (Full Name)
Mother of Deceased (Full Maiden Name)
Relationship to deceased:,,,, .Other::.
Reason for Request::
Other:.. Number of Copies:
Daytime Telephone #  () -  -Alternate Telephone #  () -  -
Ship Method:   FEDERAL EXPRESS
Ship to Name::..
Ship to Address..***>>>>>
City::................State: Zip:
Email address:
Credit Card:Expires:
Cvc Code
Signature:___________________________________________ Date:
...I authorize US Birth Certificate.net to process this death certificate for me.
All Sales Final
YOU MUST ALSO FAX A COPY OF YOUR DRIVERS LICENSE ( Call If unavailable)
***You must list a physical street address (No APO's , FPO's or PO Boxes) where someone can sign for the certificate
Please contact us if using a debit card for payments.
Please read the information on credit cards below..


Please contact us if the certificate does not arrive by the stated process time.



Please sign form in two places before faxing.
.


Is the credit card in your name?
If no... please also fax photo id of certificate holder & credit
card holder and have card holder sign authorization
below & certificate holder above.
If yes... please also sign the order form above & authorization
below & fax both pages with a photo ID.

Name of card holder: ______________________________

Signature of card holder: _____________________________________ Date:

I authorize USBirthcertificate. Net to charge my credit card for

the death certificate request of ________________________
(Certificate holder name at birth)


Credit Card Billing Address if different from shipping address:


_________________________________________________

_________________________________________________

__________________________________________________


Please fax both pages of order form, and photo id of both the certificate holder
and the credit card holder (if different from certificate holder )




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Phone: 888-736-2692
Local: 713-974-1645
Fax: 800-856-2383  
Email: info
usbirthcertificate.net
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