Death Certificate Order Form Please accurately fill out all necessary information below Fax w/ copy of photo id. to 416-962-2968 Click here to go to main page NOTE : THIS FORM IS NOT SENT ONLINE. IT MUST BE FAXED OR MAILED. MAILING ADDRESS (Please fill out all including postal code) Name: Mailing Address: Address Con't: City & Provvince: Postal Code: Daytime Telephone: E-mail: Relationship to Person Named:Reason Certificate is Required Signature:___________________________________________________ Date: DEATH CERTIFICATE (Please fill out all to order death certificate) Surname of Deceased:   Birthplace Date of Death: -Month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -Year- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 -Day- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Province of Death: City: Sex: -Select- Male Female Certificate Requested Choose One Large Small Photocopy Marital Status: Choose One Single Married Widow Divorced Date of Birth: -Month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -Year- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 -Day- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Age: Fathers Name:Mothers Maiden Name:  (Permanent Residence of Deceased prior to Death) Name on Credit Card: Credit Card Number*: Expires Choose One Visa Mastercard Signature:___________________________________________________ Date: I certify that all of the above information is true and correct to the best of my knowledge and I have a legal claim to the above document. I authorize the operators of Canadian Birth Certificate. Com or their representative to obtain my certificate for me. Choose One: Rush Delivery Regular Number of Certificates Requested Please note any special instructions for order below. We thank you for your business ! Please contact us anytime with questions or concerns. * FOR RUSH DELIVERIES: You must list a physical street address (no APO's, FPO's, or P.O. Boxes) Fax to: 416-962-2968 *If you wish to charge your shipment on a Discover or American Express, put all your credit card information in the special instructions section. All Sales Final, No Debit Cards Accepted.Process times may vary based on workload of state agencies. I understand that Canadian Birth Certiificate.Com is not responsible for any service performed by any overnight courier service or goverment agency. I understand that Canadian Birth Certificate. Com can not control the procees time by individual agencies.