ARKANSAS DEPARTMENT OF HEALTH
VITAL RECORDS, Slot 44
Date 4815 West Markham
Little Rock, AR 72205
DEATH CERTIFICATE APPLICATION
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
$
Please PRINT the name and address
of the person who is to receive this
request on the lines below.
Certificates may be ordered by the following methods: (All requests require identity verification)
Internet: ar.gov/vitalrecords A $5.00 non-refundable processing fee and a $1.85 identification
verification fee will be charged in addition to any expedited shipping options selected. Fees can
be paid by debit or credit card (VISA, Mastercard, Discover, or American Express). Requests
typically take 7 - 14 business days from the date your order is approved plus shipping time.
Telephone: Toll free (866) 209-9482. The service fee and the certificate fee are charged to
your debit or credit card (Visa, Master Card, Discover or American Express). Overnight
shipping is available for an additional fee.
Mail: Mail this application, a copy of your photo ID, and your check or money order to:
Arkansas Department of Health
Vital Records Section-Slot 44
4815 West Markham Street
Little Rock, AR 72205
The fee must be sent along with the application. Make the check or money order payable to the
Arkansas Department of Health. DO NOT SEND CASH. Please allow 7-14 days for processing.
Walk-in: Bring your photo ID and this completed application to the 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. Please order family history and
genealogy by mail or online.
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)
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 .
Death records can be requested online, by telephone, by mail, or in-person.
The fee is $10.00 for the first certified copy requested and $8.00 for each additional certified copy of the record. If no record is found, $10.00 will be kept to
cover the search charge. Only the names and dates listed will be searched for the $10.00 fee.
