Form VS-82D-FD "Funeral Director Application for a Certified Copy of a Death Record" - Rhode Island

What Is Form VS-82D-FD?

This is a legal form that was released by the Rhode Island Department of Health - a government authority operating within Rhode Island. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the Rhode Island Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form VS-82D-FD by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Health.

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Download Form VS-82D-FD "Funeral Director Application for a Certified Copy of a Death Record" - Rhode Island

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Please Print Clearly
Funeral Director Application for a Certified Copy of a Death Record
At the City/Town Office in:
Please complete ALL items 1-4 below:
1. Please fill in the information below for the person whose death record you are requesting:
Full name
Date of death
Place of death (city/town/hospital name)
2. Complete this statement:
I am representing the funeral home that handled the service for the above-listed decedent. Name of Funeral
Home:
3. Walk-In Copies cost $22. Mail-In Copies cost $25.
Additional copies of this record purchased the same day cost $18 each.
Number of copies:
4. I hereby state that the information supplied in item #2 above is true and that I am not in violation of Section 23-3-28 of
the General Laws of RI printed below.
Please sign
signature of person filing this form
date
Print your name
Print your address
street or mailing address
city/town
state
zip code
************************BELOW THIS LINE FOR OFFICE USE ONLY**************************************************************
Type of picture ID:
ID number:
ID issued by:
Personally known to:
signature of office employee
State/Local File #
Amt. rec’d
Rec’t #
Date sent
Initials
Number of first copies
Number of additional copies
Section 23-3-28 of the General Laws
I understand that Section 23-3-28 of the General Laws of Rhode Island provides penalties for either of the following
violations:
Any person who willfully and knowingly makes any false statement in a report, record, certificate or application for an
amendment thereof, or who willfully and knowingly supplies false information intending that such information be used in
the preparation of any of the such report, record, or certificate, or amendment thereof . . . . . shall be punished (if
convicted) by a fine of not more than one thousand dollars ($1,000) or imprisoned not more than one (1) year or both.
VS-82D - FD(7/1/18)
Please Print Clearly
Funeral Director Application for a Certified Copy of a Death Record
At the City/Town Office in:
Please complete ALL items 1-4 below:
1. Please fill in the information below for the person whose death record you are requesting:
Full name
Date of death
Place of death (city/town/hospital name)
2. Complete this statement:
I am representing the funeral home that handled the service for the above-listed decedent. Name of Funeral
Home:
3. Walk-In Copies cost $22. Mail-In Copies cost $25.
Additional copies of this record purchased the same day cost $18 each.
Number of copies:
4. I hereby state that the information supplied in item #2 above is true and that I am not in violation of Section 23-3-28 of
the General Laws of RI printed below.
Please sign
signature of person filing this form
date
Print your name
Print your address
street or mailing address
city/town
state
zip code
************************BELOW THIS LINE FOR OFFICE USE ONLY**************************************************************
Type of picture ID:
ID number:
ID issued by:
Personally known to:
signature of office employee
State/Local File #
Amt. rec’d
Rec’t #
Date sent
Initials
Number of first copies
Number of additional copies
Section 23-3-28 of the General Laws
I understand that Section 23-3-28 of the General Laws of Rhode Island provides penalties for either of the following
violations:
Any person who willfully and knowingly makes any false statement in a report, record, certificate or application for an
amendment thereof, or who willfully and knowingly supplies false information intending that such information be used in
the preparation of any of the such report, record, or certificate, or amendment thereof . . . . . shall be punished (if
convicted) by a fine of not more than one thousand dollars ($1,000) or imprisoned not more than one (1) year or both.
VS-82D - FD(7/1/18)