Form F-05280 "Death Certificate Application" - Wisconsin

What Is Form F-05280?

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

Form Details:

  • Released on May 1, 2018;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • 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 F-05280 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-05280 "Death Certificate Application" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Wis. Stat. § 69.21
F-05280 (Rev. 05/2018)
Page 1 of 2
WISCONSIN DEATH CERTIFICATE APPLICATION
TYPE or PRINT.
(for Mail or In-Person Requests)
PENALTIES: Any person who illegally possesses any vital record with knowledge that the vital record has been illegally obtained is guilty of a Class I felony [a fine of not more than
$10,000 or imprisonment of not more than 3 years and 6 months, or both, per Wis. Stat. § 69.24(1)].
CURRENT NAME - First
Last
MAIL TO NAME - First (if different)
Last
YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No.
MAIL TO ADDRESS (if different than street address)
Apt. No.
City
State
ZIP Code
City
State
ZIP Code
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS
(
)
TYPE OF CURRENT VALID PHOTO ID
STATE OF ISSUANCE
EXPIRATION DATE
PHOTO ID NUMBER
(See item 4, on page 2.)
Per Wis. Stat. § 69.21, a CERTIFIED copy of a death certificate is available to applicants with a “direct and tangible interest." (A–D below)
CHECK ONE box which indicates YOUR RELATIONSHIP to the PERSON NAMED on the death certificate.
A.
I am a member of the immediate family of the person named on the death certificate.
Parent (My name is on the death certificate and my parental rights have not been terminated.)
Brother / Sister
Current Spouse
Child
Maternal Grandparent
Paternal Grandparent
Current Domestic Partner (registered in the Wis. Vital Records System)
B.
I am the legal custodian or guardian of the person named on the death certificate.
C.
I am a representative authorized by any person in category A or B, including an attorney.
Specify the person you represent: ____________________________________________________________________________________
D.
I can demonstrate the death certificate is necessary for the determination or protection of a personal or property right.
Specify your interest: ______________________________________________________________________________________________
E.
I am a direct descendent of the decedent and am requesting an uncertified copy of the death certificate.
F.
None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity purposes.)
NOTE: Stepparents, stepchildren, stepbrothers / stepsisters may only obtain certified copies as categories B–D.
PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:
FIRST COPY FEE ………………………….……………………………………………………………….………………....……
$ 20.00
___$20.00__
Fact of Death (without cause of death, manner of death, and final disposition) (sufficient for most financial transactions)
OR
Extended Fact of Death (with cause of death, manner of death, and final disposition) (for insurance benefit claims)
EACH ADDITIONAL COPY (issued at the same time as the first copy)
$ 0.00
Fact of Death ………………………………………………………....………….….. _____________________ X
$ 3.00
___________
Number of Additional Copies
$ 0.00
Extended Fact of Death …………………………………………..………….……… _____________________ X
$ 3.00
___________
Number of Additional Copies
$ 20.00
FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATION REQUESTS ARE NOT ACCEPTED.
TOTAL
___________
Submit your application materials and fee to: STATE VITAL RECORDS OFFICE / PO BOX 309 / MADISON, WI 53701-0309
Be sure to include:
completed form,
acceptable identification,
payment,
self-addressed, stamped, business-size envelope, and
any additional proof or authorization required
Make check or money order payable to: STATE OF WIS. VITAL RECORDS
NAME OF DECEDENT - First
Middle
Last
DATE OF DEATH
(MM/DD/YYYY)
PLACE OF DEATH – City, Village, or Town *
DECEDENT’S SOCIAL SECURITY NUMBER *
PLACE OF DEATH - County
DECEDENT’S AGE / BIRTHDATE *
DECEDENT’S OCCUPATION * NAME OF DECEDENT’S SPOUSE *
NAME OF DECEDENT’S PARENT *
NAME OF DECEDENT’S PARENT *
I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies of
the requested death certificate in accordance with the categories listed above.
Date Signed (MM/DD/YYYY)
SIGNATURE (Applicant)
Important: Signature and payment are required for processing.
Clear / Reset Form
*
The fields marked with an asterisk (*) do not have to be completed. The information is helpful but not required
.
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Wis. Stat. § 69.21
F-05280 (Rev. 05/2018)
Page 1 of 2
WISCONSIN DEATH CERTIFICATE APPLICATION
TYPE or PRINT.
(for Mail or In-Person Requests)
PENALTIES: Any person who illegally possesses any vital record with knowledge that the vital record has been illegally obtained is guilty of a Class I felony [a fine of not more than
$10,000 or imprisonment of not more than 3 years and 6 months, or both, per Wis. Stat. § 69.24(1)].
CURRENT NAME - First
Last
MAIL TO NAME - First (if different)
Last
YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No.
MAIL TO ADDRESS (if different than street address)
Apt. No.
City
State
ZIP Code
City
State
ZIP Code
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS
(
)
TYPE OF CURRENT VALID PHOTO ID
STATE OF ISSUANCE
EXPIRATION DATE
PHOTO ID NUMBER
(See item 4, on page 2.)
Per Wis. Stat. § 69.21, a CERTIFIED copy of a death certificate is available to applicants with a “direct and tangible interest." (A–D below)
CHECK ONE box which indicates YOUR RELATIONSHIP to the PERSON NAMED on the death certificate.
A.
I am a member of the immediate family of the person named on the death certificate.
Parent (My name is on the death certificate and my parental rights have not been terminated.)
Brother / Sister
Current Spouse
Child
Maternal Grandparent
Paternal Grandparent
Current Domestic Partner (registered in the Wis. Vital Records System)
B.
I am the legal custodian or guardian of the person named on the death certificate.
C.
I am a representative authorized by any person in category A or B, including an attorney.
Specify the person you represent: ____________________________________________________________________________________
D.
I can demonstrate the death certificate is necessary for the determination or protection of a personal or property right.
Specify your interest: ______________________________________________________________________________________________
E.
I am a direct descendent of the decedent and am requesting an uncertified copy of the death certificate.
F.
None of the above. I am requesting an uncertified copy. (Copy will not be valid for identity purposes.)
NOTE: Stepparents, stepchildren, stepbrothers / stepsisters may only obtain certified copies as categories B–D.
PURPOSE FOR WHICH CERTIFICATE IS REQUESTED:
FIRST COPY FEE ………………………….……………………………………………………………….………………....……
$ 20.00
___$20.00__
Fact of Death (without cause of death, manner of death, and final disposition) (sufficient for most financial transactions)
OR
Extended Fact of Death (with cause of death, manner of death, and final disposition) (for insurance benefit claims)
EACH ADDITIONAL COPY (issued at the same time as the first copy)
$ 0.00
Fact of Death ………………………………………………………....………….….. _____________________ X
$ 3.00
___________
Number of Additional Copies
$ 0.00
Extended Fact of Death …………………………………………..………….……… _____________________ X
$ 3.00
___________
Number of Additional Copies
$ 20.00
FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATION REQUESTS ARE NOT ACCEPTED.
TOTAL
___________
Submit your application materials and fee to: STATE VITAL RECORDS OFFICE / PO BOX 309 / MADISON, WI 53701-0309
Be sure to include:
completed form,
acceptable identification,
payment,
self-addressed, stamped, business-size envelope, and
any additional proof or authorization required
Make check or money order payable to: STATE OF WIS. VITAL RECORDS
NAME OF DECEDENT - First
Middle
Last
DATE OF DEATH
(MM/DD/YYYY)
PLACE OF DEATH – City, Village, or Town *
DECEDENT’S SOCIAL SECURITY NUMBER *
PLACE OF DEATH - County
DECEDENT’S AGE / BIRTHDATE *
DECEDENT’S OCCUPATION * NAME OF DECEDENT’S SPOUSE *
NAME OF DECEDENT’S PARENT *
NAME OF DECEDENT’S PARENT *
I hereby attest that the information provided on this application is correct to the best of my knowledge and belief and that I am entitled to copies of
the requested death certificate in accordance with the categories listed above.
Date Signed (MM/DD/YYYY)
SIGNATURE (Applicant)
Important: Signature and payment are required for processing.
Clear / Reset Form
*
The fields marked with an asterisk (*) do not have to be completed. The information is helpful but not required
.
Page 2 of 2
WISCONSIN DEATH CERTIFICATE APPLICATION
F-05280 (Rev. 05/2018)
1. What is the difference between a “certified” and an “uncertified” copy of a death certificate?
A CERTIFIED COPY:
 Is printed on security paper, has a raised seal, and shows the signature of the State Registrar or Local Registrar.
 Can be used for legal purposes.
 Can only be obtained with a direct and tangible interest as defined in Wis. Stat. § 69.20(1).
AN UNCERTIFIED COPY:
 Is printed on plain paper and marked uncertified.
 Cannot be used for identity purposes.
 Contains the same information as a certified copy.
2. Limitations on access to cause of death information
Uncertified copies of death records shall not include the extended fact of death (with cause of death, manner of death, and final
disposition) unless 50 years have elapsed from the year in which the death occurred or the applicant has a direct and tangible interest
per Wis. Stat. § 69.20(1), or is a direct descendent of the decedent.
3. How long will it take to process my request?
APPLYING IN PERSON
Requests for certified copies of death certificates are usually completed within 2 business hours of application, if the death
certificate is on file.
Requests for uncertified copies of death certificates are not completed on the same schedule as requests for certified copies.
In-person requests for uncertified copies may take up to 1 month to complete.
APPLYING BY MAIL
Requests for certified copies of death certificates may take up to 2 weeks plus mail time to complete.
Requests for uncertified copies of death certificates are not completed on the same schedule as certified copies. Mail
requests for uncertified copies may take up to 1 month plus mail time.
4. What identification is required when applying for a death certificate?
Requests for certified copies require proof of identification. Applicant’s original ID is required for in-person applications. A photocopy of
the applicant’s ID is required for mail applications.
Expired cards or documents will not be accepted.
Examples of acceptable forms of identification include:
One of these:
OR
Two of these:
 State issued driver’s license or ID card
 Bank/Earnings statement
 US Government issued photo ID
 Current, dated, signed lease
 US or Foreign passport
 Health insurance card
 Tribal or Military ID card
 Utility bill or traffic ticket
 Vehicle registration/title
If you have questions regarding this form, please call 608-266-1373
or visit our website at http://www.dhs.wisconsin.gov/vitalrecords
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