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
PERSON REQUESTING CORRECTION
Please provide your name and complete mailing address to mail the new record to
you and a phone number to contact you if there are questions regarding this request.
Person Requesting Correction:
___________________________________________________________________
Mailing Address:______________________________________________________
City/State/Zip_________________________________________________________
Daytime phone number to contact you:
Area Code (
)__________________________________
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ELIGIBILITY
Please check the applicable category for requesting a correction to a Michigan death
record:
[ ] FUNERAL SERVICE LICENSEE
[ ] NEXT-OF-KIN OF THE DECEASED PERSON NAMED ON THE RECORD
You must specify your relationship
to the decedent: _______________________
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REQUIRED DOCUMENTATION
Almost all corrections require supporting documentary evidence.
Types of supporting documents that are usually acceptable are listed below. Changes
to certain information such as names, marital status, date of birth and other key items
are subject to very specific evidentiary requirements and the required documentation may
vary. If you have specific questions or need more information, you may call the
Changes Unit at (517) 335-8660.
| Hospital records | Social Security Adminnistration documents |
| Birth records | Insurance documents |
| Marriage records | Court documents |
| Divorce records | Funeral Director records |
| Military records |
Please list below the documentary evidence you are submitting to make the correction requested:
1. ________________________________________________________________
2. ________________________________________________________________
3.
________________________________________________________________
4. ________________________________________________________________
Documentation will be returned to you when the request has
been completed.
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CHANGES REQUESTED |
|
ITEMS IN ERROR |
CHANGE(S) AS THEY SHOULD APPEAR |
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A SIGNATURE IS REQUIRED TO PROCESS THE
APPLICATION.
Signature of Person
Requesting Change: ____________________________________________
Date: ________________________
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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-0856 Rev 06/2001 MCL 333.2871(1) and
333.2891(9) and (10)
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END OF THE WRITTEN APPLICATION