Southeastern Kentucky Mortuary Service

We offer services to our clients, and one of those services is completing Death Certificates for those we serve.

DEATH CERTIFICATES

We can offer death certificate filing for the following states:

* Please note, we charge a death certificate filing fee, and a fee for each individual certificate. Kentucky Death Certificates are $6 each, Tennessee Death Certificates are $15 each. Please note: Certificates for Ohio, Indiana, Virginia, and West Virginia are based upon the area of death and will be quoted as needed. Other states may be filed, but we can not guarantee prices for filing, or certificate fees.

DEATH CERTIFICATE INFORMATION SHEET
Please fill out the below form in order for us to create the death certificate.
* Required fields.

1A. LEGAL NAME: *

1B. ONLY IF FEMALE, LAST NAME PRIOR TO MARRIAGE:

2. SEX: *

3. ACTUAL DATE OF DEATH: *

4. SOCIAL SECURITY NUMBER: *

5A. AGE LAST BIRTHDAY: *

5B UNDER 1 YEAR: (copy)

5C UNDER 1 DAY:

6. DATE OF BIRTH: *

7. COUNTY OF DEATH: *

8. PLACE OF DEATH: *

9. FACILITY NAME: *

10. CITY, STATE, AND ZIP CODE OF DEATH: *

11. BIRTHPLACE (CITY,STATE) *

12. MARITAL STATUS: *

13. SURVIVING SPOUSE (IF WIFE GIVE MAIDEN):

14. USUAL OCCUPATION: *

15. KIND OF BUSINESS OR INDUSTRY: *

16. US ARMED FORCES: *

17A. RESIDENCE STATE: *

17B. COUNTY: *

17C. CITY OR TOWN: *

17D. STREET & NUMBER: *

17E. ZIP CODE: *

17F. INSIDE CITY LIMITS: *

18. EDUCATION: *

19. HISPANIC ORGIN: *

20. RACE: *

(can choose multiple selections)

21. FATHERS NAME: *

22. MOTHERS NAME (MAIDEN): *

23A. INFORMANTS NAME *

23B. INFORMANTS RELATIONSHIP: *

23C* MAILING ADDRESS *

24. METHOD OF DISPOSITION: *

25. PLACE OF DISPOSITION: *

26. LOCATION (City, State) *

27. Your Funeral Home: *

28. Your Phone Number: *

29. Your Receiving Address *

30. Your Email address: *

31. Physician or Coroner: *

As listed on Provisional

32: Upload Provisional Report of Death:

Click or drag files to this area to upload. You can upload up to 5 files.

33: Upload Any Hospital Face Sheet

Click or drag files to this area to upload. You can upload up to 5 files.

34. Number of Certified Death Certificates to be ordered: *

35. PLEASE CHECK YOUR PREFERRED METHOD OF SHIPPING: *

USPS FIRST CLASS MAIL (NO CHARGE) Please note, for this method we are not responsible for lost certificates.
UPS- 2ND DAY AIR $25.00 UPS will not ship to P.O. Boxes
UPS-OVER NIGHT AIR $35.00 UPS will not ship to P.O. Boxes

*** Please note, shipping is how you will receive the certificates once certified, and we have them in our possession***

DEATH CERTIFICATES MAY TAKE UP TO 30 DAYS TO BE CERTIFIED, OR LONGER IF AN AUTOPSY WAS PERFORMED

VETERAN ADMINISTRATION COPIES WILL BE ORDERED AUTOMATICALLY WHEN DECEDENT IS A VETERAN. VA CERTIFIED COPIES ARE OFFERED AT NO ADDITIONAL COST.