WASHINGTON COUNTY REGISTER OF DEEDS Chapter 69.21 Wis.Stats.
432 E. WASHINGTON STREET P.O. BOX 1986 WEST BEND WI 53095 (2015-FormDC-1)
WISCONSIN DEATH CERTIFICATE APPLICATION
(for Mailor In-Person Requests)
PENALTIES: Any person who wilfully and knowingly makes a false application for a death certificate 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 s. 69.24(1)]. Any person who wilfully and knowingly obtains a death certificate for fraudulentpurposes 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 s. 69.24(1), Wis. Stats.].
I. APPLICANT INFORMATION / The information in Section I is about the person completing this application.
YOUR CURRENT NAME - First / Middle / Last
YOUR DAYTIME TELEPHONE NUMBER
() / MAIL TO ADDRESS (if different) Apt. No
YOUR STREET ADDRESS (CANNOT be a P.O. Box address) Apt. No / City / State / ZIP Code
City / State / ZIP Code / EMAIL ADDRESS
TYPE OF CURRENT VALID PHOTO ID
(See item 4 on page 2.) / PHOTOID NUMBER / STATE OF ISSUANCE / EXPIRATION DATE
II. APPLICANT’S RELATIONSHIP TO PERSON NAMED ON THE CERTIFICATE / According to Wisconsin Statute, a CERTIFIED copy of a death certificate is only available to those with a “direct and tangible interest" (categories A – E below.)
Check one box which indicates YOUR RELATIONSHIP to the PERSON NAMED on the death certificate.
A. I am the PARENT ofthe person named on the record (whose name is listed on the death certificate)
B. I am a member of the immediate family of the person named on the death certificate. (Only
those listedbelow qualify as immediate family.)
CHECK ONE:
Current Spouse Brother / Sister Grandparent Child
C. I am a representative authorized, in writing, by any of the above check boxes (categories A - B). (The
writtenand notarized authorization mustaccompany this application. See item 1 on page 2.)
Specify whom you represent. ______
D. I can demonstrate that the information from the death certificate is necessary for the determination or
protection of a personal or property right for myself/my client/my agency. (Proof is required.)
Specify your interest. ______
III. FEES / FEE IS NOT REFUNDABLE IF NO RECORD IS FOUND. CANCELLATION REQUESTS ARE NOT ACCEPTED.
Fact of Death (WITHOUTcause of death) (sufficient for most financial transactions) ………...... $ 20.00 __20.00____
OR Extended Fact of Death (WITHcause of death) (for insurance benefit claims) *
Each additional copy of the same record ( issued at the same time as the first copy)
Fact of Death ...... ______X $ 3.00 ______
Number of additional copies
Extended Fact of Death.………………………….………...... ______X $ 3.00 ______
Number of Additional Copies
TOTAL ______
Make check or money order payable to:
REGISTER OF DEEDS / Be sure to include (1) Completed form (2) acceptable identification (3) any additional proof or authorization required (4) self-addressed business-size envelope and (5) check or money order
MAIL APPLICATION AND FEE TO: REGISTER OF DEEDS PO BOX 1986 WEST BEND, WI 53095
IV. DEATH INFORMATION / NAME OF DECEDENT - First / MIDDLE / LAST / DATE OF DEATH(Month/Day/Year)
PLACE OF DEATH – City/Village/Township / COUNTY / NAME OF DECEDENT’S SPOUSE (if living)
NAME OF DECEDENT’S MOTHER First/Middle/Last name at BIRTH) / NAME OF DECEDENT’S FATHER First/Middle/Last name at BIRTH)
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 to the categories listed above.
SIGNATURE (Applicant)
 / Date Signed (Month / Day / Year)

WISCONSIN DEATH CERTIFICATE APPLICATION INSTRUCTIONS

  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.”

Is for information purposes only and cannot be used for identity or legal purposes.

Contains the same information as a certified copy.

  1. Limitations on access to cause of death information

Certified and uncertified copies of death records shall not include the extended fact of death (cause of death) unless 50 years have elapsed from the year in which the death occurred or the requestor has a direct and tangible interest per Wis. Stat. § 69.20(1), or is a direct descendent of the decedent.

  1. How long will it take to process my request?

Copies of death certificates are available from the Register of Deeds office no less than 3 weeks from the date of death.

  • Applying in Person: in-person requests for certified copies of death certificates are usually available immediately, if the death certificate is on file.
  • Applying by Mail: mail requests for certified copies of death certificates will be processed and mailed within 24 hours upon receipt of the signed request payment.
  1. What identification is required when applying for a certified copy of 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.

At least one form of ID must show your name and address. 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 or Foreign passportCurrent, dated, signed lease

Tribal or Military ID cardHealth insurance card

Utility bill or traffic ticket

Vehicle registration/title

(2018 – Form DC1)