
ARKANSAS DEPARTMENT OF HEALTH
VITAL RECORDS, Slot 44
Date
4815 West Markham
Little Rock, AR 72205
DEATH CERTIFICATE APPLICATION
Only Arkansas deaths are recorded in this office. There are only a limited number of death records filed in this office for deaths prior to February 1, 1914.
The fee is $10.00 for the first certified copy requested and $8.00 for each additional certified copy of the record. The fee must accompany the application.
Send check or money order payable to the Arkansas Department of Health. DO NOT SEND CASH. Of the total fee you send, $10.00 will be kept to cover
search charges if no record of the death is found. Only the names and dates listed will be searched for the $10.00 fee. Names and other dates submitted
later will require an additional $10.00 non-refundable fee. Mail this application, a copy of your photo id and the money to the address above. Please allow
4-6 weeks for processing.
List Below All Possible Dates of Death and Names Under Which the Certificate May be Registered. (Type or Print)
1 Full Name of
Deceased
First Name
Middle Name
Last Name
2 Date of Death
Month
Day
Year
Age of Deceased
Sex
3. Place Where
Death Occurred
If unknown, give
last place of
residence.
City or Town
County
State
City or Town
County
State
4. Name of Funeral
Home
5. Address of
Funeral Home
6. Name and Address
of Attending
Certifier
If deceased was an infant, was it stillborn?
Yes No
What is your relationship to the person whose certificate is being requested?
What is your reason for requesting a copy of this certificate?
Signature and telephone number of person requesting this certificate:
X
HOW MANY
1st Copy costs $10.00
Each additional copy costs $8.00
AMOUNT OF MONEY ENCLOSED
$
All requests for certificates require photo identification.
Certificates may also be ordered by the following methods:
Internet:
www.vitalchek.com. The service fee and the certificate fee are charged to your credit
card (Visa, Master Card, Discover or American Express). Certificates may be returned over night
for the additional shipment fee.
OR
Telephone: (866) 209-9482. The service fee and the certificate fee are charged to your credit card
(Visa, Master Card, Discover or American Express). Certificates may be returned over night for
the additional shipment fee.
OR
Please PRINT the name and address
of the person who is to receive this
request on the lines below.
Walk-in: You may order a certified copy of the death record by coming into this office. Orders
are accepted for same day issuance from 8:00 A.M. until 4:00 P.M. Monday through Friday. The
office is located at 4815 West Markham St. Little Rock, AR 72205.
Any person who willfully and knowingly makes any false statement in an
application for a certified copy of a vital record filed in this state is subject
to a fine of not more than ten thousand dollars ($10,000) or imprisoned
not more than five (5) years, or both (Arkansas Statutes 20-18-105.)
VR-8 (R 8/11)