5
Must be physician that certified death to
make a correction
(Fee Required)
MAIL APPLICATION WITH PAYMENT TO:
VITAL RECORDS CHANGES
P.O. Box 30721
Lansing, Michigan 48909
PLEASE READ AND FOLLOW INSTRUCTIONS
For additional information: (517) 335-8660, Mon-Fri 8:00 am - 5:00 pm ET
PLEASE
PRINT CLEARLY AND LEGIBLY
PHYSICIAN REQUESTING A CHANGE TO A DEATH RECORD
Physician's
Name:___________________________________________________
Mailing Address: ____________________________________________________
City/State/Zip_______________________________________________________
Daytime phone number to contact you: Area Code (
) ________________
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DECEDENT'S INFORMATION
Name of Decedent:
__________________________________________________________________
First
Middle
.
Last
Gender:
[ ] Male
[ ] Female
Date of Death: ________________________________________________________
Month
Day
Year
Location of Death: _____________________________________________________
City
County
(Pronounced place of death - specify hospital,
facility, or other location - city and county)
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INSTRUCTIONS: Please enter the correction for any items in error on
the original death certificate in the appropriate spaces below.
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26. PART I
Enter the diseases, injuries, or complications that caused the death. DO NOT enter
the
mode of dying, such as cardiac or respiratory arrest, shock, or heart failure.
List only one cause on each line.
(List IMMEDIATE CAUSE as final disease or condition resulting in death)
IMMEDIATE CAUSE
Appx. Interval Between
Onset & Death
a. _______________________________
_____________________________
Sequentially list conditions, IF ANY, leading to immediate cause.
Enter UNDERLYING CAUSE (disease or injury that initiated events resulting in death) LAST.
b. _______________________________
____________________________
c. _______________________________
____________________________
d. _______________________________
____________________________
PART II
Other significant conditions contributing to death but not
resulting in the underlying
cause given in Part I:
___________________________________________________________________
27a. Was an autopsy performed?
[ ] Yes
[ ] No
27b. Were autopsy findings available prior to completion of cause
of death?
[ ]
Yes [ ] No
28. Actual Place of Death (Home,
Nursing Home, Hospital, Ambulance) (Specify)
____________________________________________________________
29. Was case referred to medical examiner? [
] Yes [ ] No
33a. Accident, Suicide, Homicide, Natural or Pending Investigation?
(Specify)
____________________________________________________________
33b. Date of injury
________________________________________________
Month
Day
Year
33c. Time of injury __________________
[ ] AM [
] PM
33d. Describe how injury occurred
___________________________________
___________________________________________________________
___________________________________________________________
33e. Injury at work (Specify) [
] Yes [ ] No
33f. Place of injury - at home,
farm, street, factory, office building, etc. (Specify)
_____________________________________________________________
33g. Location:
Street or R.F.D. No.
____________________________________________
City, Village or Twp.
____________________________________________
State
_______________________________________________________
PART III
OTHER CHANGES REQUESTED
Please list below any changes requested relating to the medical facts of this death that
are not addressed in Part I or II of this application.
1. Item to be changed: _______________________________________________
Information as it appears now:
_______________________________________
Information as it should appear:
_____________________________________
2. Item to be changed: _______________________________________________
Information as it appears now:
______________________________________
Information as it should appear:
_____________________________________
******************************************************************
I request that an amended certificate of death be filed in accordance with the
facts set forth in this application.
Physician's
Signature: _______________________________________
Date: ____________________________
*******************************************************************
PAYMENT
The fee for correcting or changing a Michigan death record is $26.00 and
includes one
copy of the record with the changes made. Additional copies of the new record are
available for $5.00 each when ordered at the same time. Payment must be
made
by check or money order and made payable to the "State of Michigan".
| Application Fee (Non-Refundable) | $26.00 | $ __________ | |
| Includes One Certified Copy of the Record | |||
| __________ Additional Certified Copies (Each) | $ 5.00 | $ __________ | |
| ************************************************************* | |||
| TOTAL ENCLOSED | $ ___________ |
|---|
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PENALTIES: Any person who willfully and
knowingly makes false application to change or amend a Michigan
vital record may be fined not more than $1,000 and/or imprisoned not more than one (1)
year.
MCL 333.2894(1)(b) and (c).
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FOR OFFICE USE ONLY - DO NOT WRITE IN THIS AREA
DCH-0862 Rev 06/2001 MCL 333.2871(1) and
333.2891(9)(b) and (10)
**************************************************************************************
END OF THE WRITTEN APPLICATION