The Los Angeles County death record application, titled Application for Death Record and Certificate of Identity, is the form the Los Angeles County Registrar-Recorder/County Clerk (RR/CC) uses to receive mail requests for certified copies of death records. You choose an AUTHORIZED or an INFORMATIONAL copy; an authorized copy must be backed by a notarized Certificate of Identity. On FillingPDF you can fill out the form online and download or print the completed PDF. The form itself is published by the RR/CC at lavote.gov, and the request is sent to the RR/CC by mail.
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What is 76A639D?
The Application for Death Record and Certificate of Identity is the Los Angeles County Registrar-Recorder/County Clerk (RR/CC) form used to request a certified copy of a death record by mail, together with the Certificate of Identity that must be notarized for an authorized copy.
The form has three parts. The front is the application: certificate type, number of copies, the deceased person's details, your relationship to the registrant and a declaration under penalty of perjury. The reverse carries a Special Notice to Veterans with an affidavit for a free certified copy. The last page is the Certificate of Identity/Sworn Statement, with a Certificate of Acknowledgement for the notary.
The RR/CC records and maintains death records in Los Angeles County since 1877, and the form states that it can only provide copies for deaths that occurred in Los Angeles County. Two kinds of copy exist. An authorized certified copy goes to the people listed under California Health and Safety Code Section 103526. An informational certified copy carries the words "INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY" across its face and cannot be used for legal purposes. If the record is not found, the RR/CC issues a "No Record Statement".
The Certificate of Identity is worded for birth, death and public marriage records, but this application requests a death record only; it is not a request for a Los Angeles County birth certificate. The form's labels are printed in English and Spanish.
Who needs to file 76A639D?
Anyone who needs a certified copy of a death record for a death that occurred in Los Angeles County and who requests it by mail uses this form. Under Health and Safety Code 103526, as printed on the form, these people are entitled to an authorized copy:
- a member of a law enforcement agency or a representative of another governmental agency conducting official business as provided by law;
- a child, parent, legal guardian, grandparent, grandchild, sibling, spouse or domestic partner of the registrant;
- an attorney representing the registrant or the registrant's estate, or any person or agency empowered by statute or appointed by a court to act for the registrant or the estate;
- any individual described in paragraphs (1) to (8) of subdivision (a) of Section 7100 of the Health and Safety Code;
- a funeral director, or an agent or employee of a funeral establishment acting within the scope of employment, who orders copies for any of the individuals in those paragraphs.
If you are not authorized, or do not want to submit the notarized Certificate of Identity, you can request an informational copy instead. Do not use this form for a death that occurred outside Los Angeles County. Veterans or their authorized agents seeking a free copy for a veteran's pension or certain other Veterans Administration benefits complete the affidavit on the reverse; it does not apply to Social Security or other civilian benefits.
When to file 76A639D
Submit the application when you need a certified copy of a death record for a death that occurred in Los Angeles County; the form prints no filing deadline. The RR/CC mails the record within 20 working days from the date it receives the request. A request that arrives without a notarized Certificate of Identity, or with an unaccepted form of payment, is delayed or returned. The RR/CC's Death Record Mail Request page says a missing notarization delays the process, and that requests paid with an E-Check, temporary check or foreign check are rejected and sent back for a new method of payment. Veterans seeking a free copy for a pension or certain Veterans Administration benefits file the affidavit on the reverse with the same application.
Documents you need
- Notarized Certificate of Identity/Sworn Statement, signed in the presence of a notary: required for an authorized copy; optional if you request an informational copy instead.
- For an out-of-state notarization: the Certificate of Identity with "California" struck out by the notary and the state of notarization written in.
- Payment by check or money order payable to the Registrar-Recorder/County Clerk; E-Checks, temporary checks, foreign checks (except Canada and Mexico) and cash are not accepted.
- Veterans affidavit on the reverse of the application: only if you claim a free copy for a veteran's pension or certain Veterans Administration benefits.
How to fill out 76A639D
Choose the certificate type
Under CERTIFICATE TYPE, mark I am requesting an AUTHORIZED copy or I am requesting an INFORMATIONAL copy. Choose authorized only if you are on the list printed at the top of the form.
Enter the number of copies
Write how many copies you want in the NUMBER OF COPIES box. Leave the FOR RECORDER USE ONLY area blank.
Enter the date of death
Write the Month, Day and Year in the Date of Death box. The death must have occurred in Los Angeles County.
Enter the deceased's details
Print the NAME OF DECEASED (first, middle, last), the DATE OF BIRTH, the CITY OF DEATH and the NAME OF MOTHER/PARENT, legibly.
State your relationship to the registrant
In YOUR RELATIONSHIP TO REGISTRANT, write how you are related or authorized, using the list at the top of the form.
Sign the declaration of perjury
Print your name on the blank in the Declaration of Penalty of Perjury, then add the date, your signature, your DL/ID number and your phone number.
Add your mailing address
Print your NAME, STREET ADDRESS, CITY, STATE and ZIP where the record should be mailed.
Complete the veterans affidavit if it applies
Only if you claim a free copy for veteran's benefits, fill in the affidavit on the reverse: the federal or state agency, type of benefit, date, signature and the agency's address.
Complete the Certificate of Identity
For an authorized copy, enter the name(s) on the certificate and your relationship, print your name, and fill in the day, month, year, city and state. Do not sign until you are in front of a notary, who completes the Certificate of Acknowledgement.
Review, print and download the PDF
Check every entry, then download or print the completed PDF from FillingPDF. Sign the printed pages by hand, get the Certificate of Identity notarized and assemble the package described under How to submit.
How to submit 76A639D
The RR/CC accepts this request by mail. Telephone requests are not available.
- By mail: send the signed application, the notarized Certificate of Identity (for an authorized copy) and your payment to: Registrar-Recorder/County Clerk, Birth, Death and Marriage Records Section, PO Box 489, Norwalk, CA 90651-0489.
- Payment: a fee applies. Pay by check or money order made payable to the Registrar-Recorder/County Clerk. The RR/CC does not accept E-Checks, temporary checks or foreign checks (except from Canada and Mexico), and asks you not to send cash. The fee for the first copy of each record is nonrefundable. For the current amount, contact the RR/CC through lavote.gov or at (800) 201-8999, the number printed on the form.
- Outside California: have the notary strike out "California" on the Certificate of Identity and write the state where it is notarized; the RR/CC accepts the form with that change.
An authorized copy cannot be issued without the notarized Certificate of Identity. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Mailing a request for an authorized copy without the notarized Certificate of Identity; the form says mail requests for authorized copies must be accompanied by it, and a missing notarization delays the request.
- Signing the Certificate of Identity before meeting the notary; the form states it must be signed in the presence of a notary.
- Having an out-of-state notary leave "California" on the Certificate of Identity instead of striking it out and writing the state where it is notarized.
- Paying with an E-Check, a temporary check or a foreign check (other than from Canada or Mexico); the request is rejected and sent back.
- Sending cash or trying to place the request by telephone; the RR/CC does not accept cash and takes no requests by phone.
- Requesting a record for a death that did not occur in Los Angeles County; the RR/CC can only provide copies for deaths in the county.
- Writing in the "FOR RECORDER USE ONLY" area (File Number, Searched, Doubled), which is reserved for the RR/CC.
- Using the veterans affidavit for Social Security or other civilian benefits; the notice says it does not apply, even if you are a veteran.
Frequently asked questions
Is this the form for a Los Angeles County birth certificate?
No. This application requests a death record for a death that occurred in Los Angeles County. Its Certificate of Identity page is worded for birth, death and public marriage records, but the application itself is for deaths only. Check lavote.gov for the birth record request.
Who can get an authorized copy of a Los Angeles County death record?
A child, parent, legal guardian, grandparent, grandchild, sibling, spouse or domestic partner of the registrant, an attorney for the registrant or estate, a government representative on official business, or a funeral director acting for an eligible person. Others can request an informational copy.
Does the Certificate of Identity have to be notarized?
Yes, for an authorized copy. The form says the certificate must be signed in the presence of a notary, and the RR/CC says a missing notarization delays the request. If you only want an informational copy, you can skip the notarized certificate.
What is an informational certified copy of a death record?
It is a certified copy stamped across its face with "INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY". The RR/CC issues it to people who are not authorized or do not submit the notarized certificate. It cannot be used for legal purposes.
How long does it take to get a death record by mail?
The RR/CC mails the record within 20 working days from the date it receives your request. A request without the notarized Certificate of Identity, or with an unaccepted type of payment, is delayed or sent back.
How do I pay for a death record request by mail?
Send a check or money order payable to the Registrar-Recorder/County Clerk. E-Checks, temporary checks, foreign checks (except Canada and Mexico) and cash are not accepted. The first-copy fee is nonrefundable, even if only a No Record Statement is issued. Ask the RR/CC for the current amount.
I live outside California. Can I still use this form?
Yes. Have the notary strike out "California" on the Certificate of Identity and write in the state where it is notarized. The RR/CC says it will accept the form with that change, and the notarized certificate must still accompany the application.
Can I get a free copy as a veteran?
Possibly. If you are applying for a veteran's pension or certain other Veterans Administration benefits, complete the affidavit on the reverse; the RR/CC mails the certificate to the benefit agency. It does not apply to Social Security or other civilian benefits.
Can I fill out the death record application online on FillingPDF?
Yes, you can fill out the PDF on FillingPDF and download or print it. FillingPDF does not file or send it to the RR/CC, and the Certificate of Identity still has to be signed before a notary and mailed to the RR/CC with your payment.
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