Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Death Certificate Template Form

Create Accurate Records with Our User-Friendly Template

Crafting a death certificate can be a challenging task during a difficult time. This template helps you create valid and professional death certificates easily, ensuring you meet all necessary requirements. You'll enjoy the convenience of customizing fields, controlling record access, and generating documents quickly, allowing for seamless handling of sensitive situations. Plus, our template is compliant with WCAG standards for accessibility, ensuring it's usable for everyone. Explore the template now to simplify your certificate creation process.

Use this Template (FREE) Live Preview
Applicant full name
Relationship to the deceased
Please Specify:
Email address
Phone number
Mailing address (street, city, state/province, postal code, country)
Preferred contact method
Email
Phone
Mail
No preference
Decedent full name
Other names or aliases (if any)
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Date of birth
National ID or Social Security Number (if applicable)
Last residential address (street, city, state/province, postal code, country)
Marital status at time of death
Single
Married
Widowed
Divorced
Separated
Domestic partnership or civil union
Unknown
Prefer not to say
Date of death
Time of death (HH:MM, include AM/PM if applicable)
Place of death
Hospital
Home
Hospice facility
Nursing home or long-term care facility
Outdoors or public place
Unknown
Other
Please Specify:
Facility name and address where death occurred (if applicable)
Cause(s) of death (as listed by the medical provider, if known)
Method of disposition
Burial
Cremation
Donation to science
Other or unknown
Purpose of request
Personal records
Legal proceedings
Insurance claim
Estate or probate
Government benefits
Genealogy or family history
Other
Please Specify:
Number of certified copies requested
1
2
3
4
5
More than 5
Not sure
Preferred delivery method
Mail (paper copy)
Pick up in person
Digital copy if available
No preference
I confirm I am legally entitled to request or receive this death certificate.
Yes
No
I certify the information provided in this application is true and correct to the best of my knowledge.
Yes
No
Typed signature (enter your full name)
Signature date
I acknowledge that valid identification and any required documents may be requested before issuance.
Yes
No
{"name":"Applicant full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Applicant full name, Relationship to the deceased, Email address","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration featuring a death certificate template for FormCreatorAI article

When to use this form

This form helps you collect the facts needed to prepare a record of death before you apply for certified copies from your local vital records office. Use it in hospitals or hospice to document details at the time of passing, in funeral homes to coordinate information with families, or as an executor to organize data for banks, insurers, and the court. HR or benefits teams can request a completed form to verify bereavement claims. To gather background efficiently from relatives or care teams, pair it with our Medical questionnaire form. Note: this template is for documentation and review; it does not replace an official government record.

Must Ask Death Certificate Questions

  1. Full legal name of the deceased (include any aliases or maiden names)

    This identifies the person exactly as it appears on IDs and past records, reducing mismatches. Accurate names prevent delays with banks, insurers, and the court.

  2. Date and exact place of death (facility, city, state)

    Jurisdiction and facility details tell agencies where to file and which authority certifies the record. Precise location helps benefits administrators and researchers verify events.

  3. Date of birth and legal identifiers (e.g., national ID or last four of SSN)

    Birth details and an identifier help match the correct file and avoid mixing records for people with similar names. Collect only what your jurisdiction allows; many accept just the last four digits.

  4. Immediate cause of death and manner of death (as certified)

    Listing the immediate and underlying causes supports public health reporting and insurance decisions. If you need clinical detail, compile it with a Medical chart review form for the certifying provider.

  5. Informant or next of kin name, relationship, and contact details

    Contact info lets agencies follow up for corrections and send copies. Relationship confirms the informant has authority to provide or receive details.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel