Funeral Establishment / Government Agency Application Submission

Name of Funeral Home
Name of Funeral Home Director

First NameLast Name
Funeral Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Funeral Home Email Address
example@example.com

What type of applications are you submitting?
Proof of ID of Applicant (Drivers License Photo of Requester at Funeral Home)

Only Required for Death Certificate Applications
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Please upload all of the applications for the records you are requesting in the box below.

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Name of Government Organization
Name of Requester

First NameLast Name
Government Organization Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address of Requester
example@example.com

Pursuant to Colorado Revised Statutes, 1982, 25-2-118 and as defined by Colorado Board of Health Rules and Regulations, applicant must have a direct and tangible interest in the record requested. The penalties for obtaining a record under false pretenses include a fine of not more than $1,000or imprisonment in the county jail for not more than one year or both such fine and imprisonment (CRS 25-2-118). By signing below, I have read and understood that there are penalties for obtaining a record under false pretenses.
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