Death Certificate Request Form - VitalCertificates.ca

ContactInformationApplication for Yukon Death CertificateAlthough you can fill out the application online, you cannot save or email it. Please type, print and sign the application then fax, scan and emailor 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.Full Name: _______________________________________________________________Mailing Address: ___________________________________________________________________ Apartment: ________City: ______________________ Prov./State: _____________________ Country: ___________________ Postal/Zip Code: ____________Daytime Telephone: (_______) ______________________ Extension: ________ Home Telephone: (_______) ______________________Email Address: _________________________________________________ (If no email address is provided, your receipt will be mailed to you)ApplicationYou must enter as much information as possible. If information is missing or does not match the original death registration theremay be delays in processing your application.Reason Certificate Required: __________________________________________________Name of Deceased: ________________________________ ________________________________ ________________________________First Name Middle Name(s) Last NameDate of Death: _____________________ _____ ________ Place of Death: ______________________________, YUKONMonth Day Year City/TownAge at Death: _____ Male FemaleMarital Status at Time of Death: ____________________Permanent Residence Prior to Death: City: _____________________ Prov./State: ____________________ Country: __________________PaymentInformationCertificates 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 Death Certificate.____ Qty. - Death Certificate - $57.25 eachCredit 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 besubject to bank clearing and may take up to 7 days. Applications received with a personal cheque will be held until such time as thecheque 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.caor Regular Mail: Express Legal, 79 - 622 Front Street, Nelson, BC V1L 4B7continued on next page

Death CertificateAuthorizationBy signing this authorization, you are permitting Express Legal to request one or more Certificatesof Death. Your certificate(s) will be sent to you directly from the government agency. Acompleted and signed authorization must be provided.I, ___________________________________, hereby authorize Express Legal to request(Type/Print Name)one or more Certificates of Death from the Yukon Vital Statistics Agency on my behalf.Date: __________________________Signature: ______________________________Toll Free Telephone: 1.866.828.9680 Toll Free Fax: 1.866.265.6300 Email: support@expresslegal.caExpress Legal, 79 - 622 Front Street, Nelson, BC, Canada V1L 4B7