Death Certificate Application - Southern Nevada Health District

For more information call
(702) 759-1010

Death Certificate Application Southern Nevada Health District - Vital Records Office P.O. Box 3902 - 625 Shadow Lane Las Vegas, NV 89127 (702) 759-1010
PHOTO ID REQUIRED
Photo identification of the requestor and the credit card holder is required to process the online application. A photo ID must be uploaded to submit the online application. If you're unable to upload a photo ID, please return to Vital Records and complete the fax application or apply in person.

Number of Copies:*

Application Information

Full Name of Deceased:
	First Name:*
	Middle Name:
	Last Name:*

Date of Death [mm/dd/yyyy]:*

Place of Death:*

Full Name of Father of Deceased:
	First Name:*
	Middle Name:
	Last Name:*

Maiden Name of Mother:*

Mortuary in Charge of Arrangements
Mortuary Name:*
	Street:*
	City:*
	State:*
	Zip Code:*
	Country:*

Purpose for which Certificate is Used:*

Relationship to Deceased:*

Your Name:*
	First Name:*
	Middle Name:
	Last Name:*

Your Mailing Address:*
	Street:*
	City:*
	State:*
	Zip Code:*
	Country:*

Notice: Nevada law states that the possession, sale and transfer of identity information is punishable by law.

Shipping Information

Ship To Name: (If different from 'Your Address' above)
Mailing Address:
City:
State:
Zip Code:
Country

Credit Card Information
We only accept Visa and Mastercard.
Credit Card Number:*
Expiration Date:*
3 Digit Security Code:*
Cardholder Name as it appears on card:*
Card Holder Address:*
City:*
State:*
Zip Code:*
Country:*
Phone:*
Email Address:*
Photo ID [.jpg /.gif]: *
Please note: Photo ID should be scanned at 300 DPI for best resolution. If we are unable to read the information of your ID due to poor scan quality your application will not be processed.

Death Certificates will be sent via USPS mail Requestor's name and address must match the billing name and address of the credit card. Each Certificate is $20 USD