Application for Alberta Death Certificate - VitalCertificates.ca

Application for Alberta Death Certificate
Although you can fill out the application online, you cannot save or email it. Please type, print and sign the application then fax, scan and email
or mail your application to us. A receipt, along with your order information, will be issued and sent to you by email or mail.
Important Note: Applications are processed upon receipt. As such, we cannot change or cancel applications once received.
ContactInformation
Full Name: _______________________________________________________________
Daytime Telephone: (_______) ______________________ Extension: ________ Home Telephone: (_______) ______________________
Mailing Address: ___________________________________________________________________ Apartment: ________
City: ______________________ Prov./State: _____________________ Country: ___________________ Postal/Zip Code: ____________
Email Address: _________________________________________________ (If no email address is provided, your receipt will be mailed to you)
Application
You must enter as much information as possible. If information is missing or does not match the original death registration there
may be delays in processing your application. If you are legal counsel please telephone 1-780-415-2225 to obtain your client’s
certificate.
Reason Certificate Required: ________________________________________
Name of Deceased: _____________________________ _____________________________ _____________________________
First Name Middle Name(s) Last Name
Date of Death: _____________________ _____ ________ Age at Death: _____ Male Female
Month Day Year
Place of Death: _____________________________, ALBERTA
City/Town
Date of Birth: _____________________ _____ ________
Month Day Year
Marital Status at Time of Death: _______________________
Usual Residence Before Death: _____________________________ ____________________________ ____________________________
City/Town Province Country
PaymentInformation
Certificates take approximately 10 to 15 business days to be processed and delivered. All delivery times quoted are average delivery times,
and cannot be guaranteed. All taxes and shipping costs are included. Please see website for description of each version of certificate.
___ Qty. - Death Certificate - $87.25 each
___ Qty. - Certified Copy of Death Registration - $87.25 each
Rush Service - 4 to 7 business days (includes mailing time - is not couriered) - $25.00 additional Vital Statistics ‘Rush’ processing fee
Credit Card Type: (or) Phone me for credit card details (cardholder must still sign below).
Credit Card Number: _____________________________________________
Exp. Date: ___________
Name of Cardholder: ________________________________________ Signature: _______________________________________
If paying by money order or certified cheque please mail the completed application along with your payment. Personal cheques will be
subject to bank clearing and may take up to 7 days. Applications received with a personal cheque will be held until such time as the
cheque clears. Payment must be made payable to ‘Express Legal’. Any questions, please telephone us toll-free at 1-866-828-9680.
Please return your completed application and authorization to us by one of the following methods:
Toll-Free Fax: 1-866-265-6300, Scan & Email: support@expresslegal.ca
or Regular Mail: Express Legal, 79 - 622 Front Street, Nelson, BC V1L 4B7
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Death Certificate
Authorization
RegistryConnect
10237 – 104 St.
Edmonton,AB
T5J 1B1
Towhomitmayconcern,
RE:Application forDeath Certificate
I, _________________________________________ authorize David Shelly, to obtainone or more death
(provide full name)
certificate(s). I am a next-of kin (mother, father, brother, sister, children, spouse, or common-law spouse).
My home address is:
Address: ___________________________________________ Apartment: _______
City: _________________________ Prov./State: _________________________
Postal/Zip Code: _______________ Country: _________________________
My home phone number is:
(______) ________________________
Pleasehavemycertificate(s) senttomyhomeaddress.
Sincerely,
Date: ____________________
Signature: ________________________________
(signature must be provided)
ImportantNote:DonotmailthisauthorizationlettertoRegistryConnect.
Please return by one of the following methods:
Toll-Free Fax: 1-866-265-6300, Scan & Email: support@expresslegal.ca
or Regular Mail: Express Legal, 79 - 622 Front Street, Nelson, BC V1L 4B7