Yukon Death Certificate Application - VitalCertificates.ca

Yukon Death Certificate ApplicationPLEASE NOTE: In Yukon, anyone with a valid reason may apply for a death certificate.Applications are processed upon receipt. We cannot change or cancel applications once received.Should you believe that you require a certified photocopy of a death event registration please contactthe Yukon Vital Statistics Agency directly at 867-667-5207.Although you can fill out the application online, you cannot save or email it. Please type, print and signthe application then fax, scan and email or mail your application to us.Step 1 - Contact Information - Person applying Contact for InformationcertificateName: ___________________________________________ApplicantFirm/Organization: ____________________________________________Complete only if certificate to be delivered here.Telephone Number: (_____) _________________ Extension: ______ Daytime Number: (_____) _________________ Extension: ______Mailing Address: ________________________________________________________ Apt.: __________ _ Buzzer Code:____________City: _________________________ Prov./State: _________________ Country: _________________ Postal/Zip Code:________________Email Address: ___________________________________________________________________________________________________Step 2 - Details of Deceased - Person named on certificateYou must enter as much information as possible. Missing or incorrect information may delay your application.Reason Certificate Required: ________________________________________________________________________________________Please specify reason (Example: Settle Estate, Pension, etc... )Name of Deceased: _____________________________ _____________________________Certificates take approximately 10 to 15 days to be processed and delivered. Delivery times are average delivery times and cannot be guaranteed.All taxes and shipping included.____ Qty. - *Death Certificate - $60.00First Middle - Must provide full name if known LastDate of Death: ________________ ___________ ___________Month Day Year City/TownAge at Death: ________________ Gender: Male FemaleStep 3 - Payment Information - Select certificate type and payment method**Add Rush Service to Order - 5 to 8 business days - $20.00 additional Vital Statistics Rush processing fee.* Death Certificate: Contains Full name of the deceased, date of death, place of death, gender, age, marital status, name of spouse, registration number and registration date.** Rush Service: Price quoted above represents an additional cost. Please add the rush service cost to the price of the certificate (ex. $60.00 + $20.00 = $80.00).Credit Card Type: (or) Phone me for credit card details. Phone No. (_____) ________________Credit Card Number: _____________________________________________ Exp. Date: _____________________________________________Place of Death: ____________________________________, YukonPermanent Residence Before Death: _____________________________ _________________________ _________________________City/Town Province/State CountryMarital Status at Time of Death: ________________________________(Married, Common-Law, Divorced, Widowed, Single)Name of Cardholder: _____________________________________________ Cardholder Email:__________________________________Type/Print NameSignature: ______________________________________________________ Date: _______________Charge will appear as “Express Legal” on credit card statement.If paying by money order or certified cheque please mail the completed application along with your payment.Any application received with a personal cheque will be held until such time as the cheque clears, typically 7 to 10 days.Cheques and money orders must be made payable to ‘Express Legal’.

Step 4 - Provide AuthorizationYukon Death Certificate AuthorizationBy signing this authorization, you are permitting Express Legal to request a certificate ofdeath. Your certificate will be sent to you directly from the government agency. Acompleted and signed authorization must be provided.I, ___________________________________, hereby authorize Express Legal to requestFull Legal Name of Applicantone or more certificates of death from the Yukon Vital Statistics Agency on my behalf. Ifurther authorize Express Legal to correspond in writing or orally with the Yukon VitalStatistics Agency with respect to this application.Date:_________________ / _________ / ___________Month Day YearSignature:_________________________________________Applicant - Signature must be providedStep 5 - Submit ApplicationPlease return your completed application andauthorization to us by one of the following methods:Toll-Free Fax: 1.866.265.6300or Scan & Email: yukon@expresslegal.caor Regular MailExpressLegal, 79-622 Front Street, Nelson, BC V1L 4B7Toll-Free Phone: 1.866.828.9680IMPORTANT NOTES: • If information is missing from the application or if additional information is required, we willcontact the applicant by telephone or email.• All information submitted is strictly confidential and will not be used for any reason other thanobtaining the requested document from the respective government agency.