*** Transcriber's Note: Please set your voice synthesiser to read most punctuation. When you encounter the caret sign at the end of a line, please enter the applicable information, if necessary. *** Internal Affairs Te Tari Taiwhenua BDM93D Tono Tiwhikete Mate o Aotearoa, Tānga rānei Request for New Zealand Death Certificate or Copy of Record Order certificates online at www.govt.nz/bdm If you intend to use the certificate overseas refer to www.govt.nz/authentications Section 1: Certificate details Deceased's surname (required) ^ Deceased's first and middle names (required) ^ Date of death (required) ^ Place of death (town or city) ^ Spouse/Partner's full name (if any) ^ Deceased parent 1 full names ^ Deceased parent 2 full names ^ Other information ^ Section 2: Delivery and contact details Delivery name ^ Flat no ^ Street no ^ Street name ^ Suburb or rural locality ^ City, town or district ^ Postcode ^ Country (if not New Zealand) ^ Applicant's contact phone number ^ Applicant's email address ^ Section 3: Certificate style and quantity Select the certificates you want, and write the quantity you want of each The certificate will be sent folded with the delivery address printed on the back. Death certificate $33.00 Quantity ^ Copy of the record $25.00 This is a copy of the death record and is usually used for genealogical research and is not a legal document. It is typed or handwritten. Quantity ^ If the record cannot be found we will contact you and search fees will apply. Section 4: Payment I want the certificate(s) sent by standard post $0.00 Yes or No ^ I want the certificate(s) or copy of the record couriered to a New Zealand address $5.00 Yes or No ^ I want the certificate(s) or copy of the record couriered to an overseas address Australia, Asia, Pacific $15; USA $20; Europe $25; Rest of the world $30 Yes or No ^ I am ordering a copy of the record and want it emailed $0.00 Yes or No ^ I am ordering a copy of the record and want it sent by standard post $0.00 Yes or No ^ Select how you will pay Do not post cash Visa Yes or No ^ Mastercard Yes or No ^ American Express Yes or No ^ Prezzy card Yes or No ^ Do not post us your prezzy card Card number ^ Expiry date ^ Card verification value ^ Name on card ^ Cardholder signature ^ Section 5: Proof of identity We check your details in this form against another identity record Choose one of the following to confirm your identity I was born in New Zealand Yes or No ^ I was married or entered into a civil union in New Zealand Yes or No ^ Date of marriage or civil union ^ Town or city of marriage or civil union ^ My child was born in New Zealand Yes or No ^ Child's date of birth ^ Child's full name ^ OR include a photocopy of one of the following identity documents. Do not send the original: Yes or No ^ - Passport (NZ or overseas) - Drivers licence (NZ or overseas) - 18+ Card (issued by Hospitality NZ) - NZ Firearms or Dealer’s Licences - Salvation Army identity certification - NZ Refugee Travel Document - NZ Emergency Travel Document - NZ Certificate of Identity (Issued by Immigration NZ) - NZ Certificate of Identity (Issued under the Passport Act 1992) - Steps to Freedom document (issued by Department of Corrections) Section 6: Declaration My first and middle names ^ My surname ^ My first and middle names at birth (if different) ^ My surname at birth (if different) ^ My date of birth ^ My town or city of birth, and country if not NZ ^ I am ordering on behalf of a company, and have included a signed request on company letterhead Yes or No ^ I declare that the information above is true and correct. I understand that any person who makes a false statement will be liable on conviction to a fine or imprisonment, or both. I understand the information on this form is collected under the Births, Deaths, civil unions, and Relationships Registration Act 1995. As part of processing my request, I understand that my identification details will be checked against other records held by the Department of Internal Affairs or other government agencies, as authorised by law. I understand that my name will be recorded on the access register for any non-historical certificates that I order. My signature ^ Date signed ^ Submit your form and payment By mail Certificate Team Births, Deaths and civil unions PO Box 10526 Wellington 6143 New Zealand In person Visit www.govt.nz/bdmoffices for the location of offices in Auckland, Manukau, Wellington, Christchurch, Sydney and London. Office Use Only B D Last updated 7 January 2020