Funeral Establishment / Government Agency Application Submission
Please select your organization type
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Funeral Home
Government Agency
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Name of Funeral Home
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Name of Funeral Home Director
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First Name
Last Name
Funeral Home Phone Number
Please enter a valid phone number.
Funeral Home Email Address
example@example.com
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What type of applications are you submitting?
*
Please Select
Death Certificate Applications
Drop to Paper Worksheet Form
Fetal Death Certificate
Proof of ID of Applicant (Drivers License Photo of Requester at Funeral Home)
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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
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Name of Requester
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First Name
Last Name
Government Organization Phone Number
*
Please enter a valid phone number.
Email Address of Requester
*
example@example.com
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Please attach a copy of your Government ID badge
*
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Please upload all of the applications you are requesting in the box below
*
Browse Files
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Choose a file
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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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