On line copy death certificate application form

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On line copy death certificate application form

If you require assistance please contact:

Superintendent Registrar
Derby Register Office
Royal Oak House
Market Place
Derby
DE1 3AR

Tel: 01332 256526/ 256535/36

Fax: 01332 256525

Minicom: 01332 256666

Email: registeroffice@derby.gov.uk

For a printable version of this form please go to the copy certicates page.

You should only use this form if the event concerned occured within Derby City or South Derbyshire Registration District.

Application Form

Fields marked with '*' are required fields.

Title	*
Other title
Last name	*
First name	*
House number or name	*
Street	*
Town	*
City	*
County	*
Postcode	*
Relationship to person named below	*
Reason for applying for certificate	*
Deceased person's last name	*
Deceased person's first name	*
Person's date of birth
Date of death	*
Address at time of death for example address of hospital where the death occurred
Deceased person's home address
Person's husband/wife name
Person's occupation or last occupation

Data Protection: This form is not secure. Please don't include any confidential or sensitive information on it. We will treat any other personal information you provide in confidence and under the Data Protection Act 1998. We will hold it and only use it for a legal reason or for the purpose it is given. We will only share information when we have your consent or we need to ask another department or partner to respond to a specific comment or request you have made.

We will keep a record of the sender's Internet Protocol address (which is unique to the sender's computer), the date we received the form, and the content for back-up and archive purposes. We will also use this record to identify senders of any malicious content under the Protection from Harassment Act 1997. We will keep this record for a maximum of three months.

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