Affidavit to Amend a Death Record

January 2022 Office of Vital Records Page 1 of 8

Center for Health Statistics and Informatics – California Vital Records

Effective January 2022

Introduction

Use the VS 24 - Affidavit to Amend a Record form to:

 Correct most typographical or spelling errors

 Add most information not known at the time of death

 Add an AKA (“also known as”) for the decedent

 Please see page 8 for a list of frequently asked questions and answers

 If amending the death certificate within one (1) year of date of death, the funeral

home assisting to register the certificate may submit an electronic amendment.

 To establish a court order delayed death certificate, please see Court Order

Delayed Registration of Death informational pamphlet.

 For other amendment types, please visit the CDPH-VR website at www.cdph.ca.gov.

What to Submit and Mailing Address

To request an amendment, please submit the following:

 Properly Completed VS 24 Form (See Form Guidelines beginning on page 3.)

 Notarized Sworn Statement (Only if requesting authorized copy. See page 6.)

 Appropriate Fee(s) (See top of page 7.)

 Supporting Documentation (See bottom of page 7.)

Mail your packet to the address below:

California Department of Public Health

Vital Records – Amendments – M.S. 5105

P.O. Box 997410

Sacramento, CA 95899-7410

 Amended certificates are returned via standard mail and do not contain a

tracking number.

 You may provide a prepaid self-addressed envelope with your request for

CDPH-VR to use and mail the amended certificate back to you. (Not Required)

VS 24 - Affidavit to Amend a Death Record Checklist

To assist in the registration of your amendment, please submit the following:

Properly Completed VS 24 Form

The form is completed in black ink and does not contain any alterations or writing in the margins.

Part I matches the current death certificate, (even if the information is incorrect).

Part II, column 8 lists the current death certificate’s item number that needs correction.

Part II, column 9 lists the incorrect information as it appears on the current death certificate.

Part II, column 10 lists the correct information as it should appear on the amended certificate.

Part II, item 11 lists a reason for correction.

Fields 12A through 13E are completely filled out with proper signatures.

I am changing the decedent’s date, time, or cause of death.

REQUIRED: One of the signatures is the certifying or attending physician, coroner, or medical

examiner.

The back of the form (or second page if printed) lists payment information, and the name, phone

number, and mailing address of the applicant, (person submitting the application).

Payment

I am submitting the amendment WITHIN ONE (1) YEAR of date of death:

There is no fee to register the amendment and I do not want a copy of the amended certificate.

I would like a copy of the amended certificate, and I have enclosed a check/money order

(payable to CDPH Vital Records) in the amount of twenty-four dollars ($24) per copy.

I am submitting the amendment ONE (1) YEAR OR MORE AFTER the date of death:

I have enclosed a check/money order (payable to CDPH Vital Records) in the amount of

twenty-six dollars ($26) for the registration of the amendment, which includes one copy

of the amended certificate.

I would like additional copies of the amended certificate, and I have enclosed a

check/money order (payable to CDPH Vital Records) in the amount of twenty-four dollars

($24) per additional copy requested.

Notarized Sworn Statement

I have requested copies of the amended certificate and would like the copies to be authorized copies.

I have enclosed a notarized sworn statement, (not required if requesting informational copy).

Optional Item

Photocopy of death certificate, if available.

For more information visit our website at cdph.ca.gov.

January 2022

Page 2 of 8

Affidavit to Amend a Death Record

January 2022 Office of Vital Records Page 3 of 8

Form Guidelines

To prevent processing delays, please adhere to the following guidelines on

how to complete the Affidavit to Amend a Record (VS 24) form.

General Information

The VS 24 form must:

 Be completed legibly in black ink using the 26 alphabetical characters of the

English language.

 Not contain any write-overs, whiteouts, alterations, drawings, symbols,

accents, or other marks to indicate pronunciation or to distinguish letters in

some way, such as è, ñ, ē, or ç.

Part I

PART I must match the current certificate. This means:

 It should show any incorrect information as it appears on the current record.

 If any of the information in Part I was previously amended, the changes must

be reflected in Part I of the VS 24 form.

Part II (Column 8)

PART II Column 8 must list the certificate item number that needs correction.

NOTE: This is the number located on the top left corner of the box being corrected

on the death certificate.

Affidavit to Amend a Death Record

January 2022 Office of Vital Records Page 4 of 8

Form Guidelines (Continued)

Part II (Column 9)

Part II Column 9 must list the incorrect information as it appears on the current

death certificate.

Part II (Column 10)

Part II Column 10 must list the correct information as it should appear on the

death certificate.

 An AKA is used to add names the decedent was also known as. See sample above.

 If amending the decedent’s date of birth, please correct the age as well, as

necessary.

Reason for Correction (Box 11)

Box 11 must contain a reason for correction. Please see requirements below

when correcting the attending physician or coroner’s error:

 If changing the decedent’s name, sex, date of death, hour of death, place of

death, or cause of death due to the attending physician’s error, the reason

for correction must state “To correct physician error.”

 If changing the decedent’s name, sex, date of death, hour of death, place of

death, or cause of death due to the coroner’s error, the reason for correction

must state “To correct coroner error.”

Affidavit to Amend a Death Record

January 2022 Office of Vital Records Page 5 of 8

Form Guidelines (Continued)

Affidavit and Signatures

Two people with knowledge of the facts must sign and complete the Affidavit

and Signatures section. Please see requirements below when correcting the

attending physician or coroner’s error:

 If changing the date of death, hour of death, or cause of death due to a

clerical or typographical error, one of the signer’s must be the attending

physician.

 If changing the date of death, hour of death, or cause of death due to a

clerical or typographical error, one of the signers must be the coroner.

End of Form Guidelines section.

Affidavit to Amend a Death Record

January 2022 Office of Vital Records Page 6 of 8

Notarized Sworn Statement

An authorized person must submit a notarized sworn statement to receive a certified

authorized copy of the amended certificate. Please see list of authorized persons below:

 Child/Sibling of Registrant

 Grandparent/Grandchild of Registrant

 Authorized by Court Order (Include

copy of court order.)

 Law Enforcement/Govt. Agency

(Conducting Official Business)

 Parent/Legal Guardian of Registrant

(Legal guardian must provide

documentation.)

 Spouse/Registered Domestic Partner

of Registrant

 An Agent or Employee of a Funeral

Establishment (Acting within the scope of

employment and on behalf of persons

specified in HSC Section 7100 (a)(1)-(8))

 Attorney Representing Registrant or

Registrant’s Estate

 Power of attorney/Executor of the

registrant’s Estate (Include a copy of the

power of attorney or supporting

documentation identifying you as executor.)

 Individuals (As specified in HSC Section

7100 (a)(1)-(a)(8))

The notarized sworn statement must:

 Include a penalty of perjury statement

 Identify the applicant’s relationship to the registrant

 Be signed in the presence of a notary public

 Contain the notary’s official seal. (NOTE: A sworn statement notarized by a foreign

notary must have an apostille attached. Foreign notarizations obtained at a United

States Embassy or Consulate do not require an apostille.)

Please see sample sworn statement below. (The notary completes the Certificate of

Acknowledgment section after the applicant’s signature is witnessed.)

Affidavit to Amend a Death Record

January 2022 Office of Vital Records Page 7 of 8

Appropriate Fee(s)

If Amending the Death Record Within One (1) Year of Date of Death:

 There is no fee to register the amendment, however a certified copy of the certificate

will not be issued.

 The fee for each certified copy of the amended record is twenty-four dollars ($24). There

is no fee to register the amendment, but you must pay a fee to receive a certified copy

of the amended record.

 Checks or Money Orders must be made payable to CDPH Vital Records.

If Amending the Death Record One (1) Year or More From Date of Death:

 There is a twenty-six dollar ($26) registration fee, which includes one (1) certified

copy of the amended certificate.

 Additional certified copies are twenty-four dollars ($24) each.

 Checks or Money Orders must be made payable to CDPH Vital Records.

Supporting Documentation

It is preferred that you submit documentation supporting the amendment requested. If

available, please submit any applicable documents listed below:

 If correcting a parent’s date of birth, place of birth, or an error in the parent’s name, it

is preferred you submit a photocopy of the parent’s birth certificate.

 If correcting the decedent’s date of birth or place of birth, it is preferred you submit a

photocopy of the decedent’s birth certificate.

 If correcting marital status, it is preferred you submit a copy of the decedent’s

marriage certificate or divorce decree. (Not Required)

Affidavit to Amend a Death Record

January 2022

Office of Vital Records

Page 8 of 8

Frequently Asked Questions

Q: Where can I find application forms?

A: Application forms, including the Affidavit to Amend a Record (VS 24) form, are located on

the CDPH-VR Vital Records, Data and Statistics Forms webpage.

(https://www.cdph.ca.gov/Programs/PSB/Pages/BirthDeathMarriageCertificates.aspx)

Q: Where can I find informational pamphlets?

A: Informational pamphlets for all amendment types are located on the CDPH-VR Vital

Record Pamphlets webpage.

(https://www.cdph.ca.gov/Programs/CHSI/Pages/Vital-Record-Pamphlets.aspx)

Q: What is the current processing time?

A: Current processing times are listed on the CDPH-VR website.

(https://www.cdph.ca.gov/ Programs/CHSI/Pages/Vital-Records-Processing-Times.aspx)

Q: Once the amendment is registered, what happens to the death certificate?

A: Amendments become part of the original record, resulting in a multi-page certificate.

You must keep the death certificate with all amendments attached for the certificate to

be valid.

Q: Will my supporting documents be returned?

A: Supporting documents, including sworn statements, are not returned once the

amendment is registered. Please keep copies of all documents submitted.

Q: What if I still have questions?

A: Please contact our Customer Service Unit by email at [email protected] or

telephone at (916) 445-2684.

State of California – Health and Human Services Agency California Department of Public Health

VS 20 (1/20)

Page 1 of 2

SWORN STATEMENT INSTRUCTIONS

• Only one sworn statement is required for multiple records.

• Sworn statements are not required for informational copy requests.

• Authorized individuals must complete the top portion of the sworn statement by signing and

identifying their relationship to person listed on certificate.

• Sworn statements must be notarized for authorized copy requests. Law enforcement,

governmental agencies, and funeral establishments (death records only) are exempt from the

notary requirement, but must complete the top portion of the sworn statement page.

• A sworn statement notarized by a foreign notary must have an apostille attached. Foreign

notarizations obtained by an Ambassador, Minister, Consul, Vice Consul or Consular Agent of the

United States, or from a Judge of Court of record having a seal in a foreign county do not require

an apostille.

RELATIONSHIP TO REGISTRANT

List of Authorized Persons:

• The registrant or a parent, legal guardian, child, grandparent, grandchild, sibling, spouse, or

domestic partner of the registrant.

• A party entitled to receive the record as a result of court order or an attorney or licensed adoption

agency seeking the birth record in order to comply with the requirements of Section 3140 or

7603 of the Family Code. (Please include a copy of the court order.)

• A member of a law enforcement agency or a representative of another governmental agency, as

provided by law, who is conducting official business. (Companies representing a government

agency must provide authorization from the government agency.)

• Any person or agency empowered by statute or appointed by a court to act on behalf of the

registrant or the registrant’s estate (Include a copy of the power of attorney or documentation

identifying you as executor.)

• An attorney representing the registrant or the registrant’s estate.

• Any agent or employee of a funeral establishment who acts within the course and scope of

employment and on behalf of persons specified in HSC § 7100 (a) (1)-(8).

• Surviving next of kin (As specified in HSC § 7100).

State of California – Health and Human Services Agency California Department of Public Health

VS 20 (1/20)

Page 2 of 2

SWORN STATEMENT

(Applicant’s Printed Name)

, declare under penalty of perjury under the laws of the

State of California, that I am an authorized person, as defined in California Health and Safety Code Section 103526

(c), and am eligible to receive a certified copy of the birth, death, or marriage certificate of the following

individual(s):

, .

Regis

trant

(Name of person whose certificate

you are requesting)

Applicant's Relationship to Registrant

(Must be an authorized person)

(The remaining information must be completed in the presence of a Notary Public or CDPH Vital Records staff.)

Subscribed to this

(Day)

day of

(Month)

, 20 , at

(City) (State)

(Applicant’s Signature)

CERTIFICATE OF ACKNOWLEDGMENT

A notary public or other officer completing this certificate verifies only the identity of the individual

who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or

validity of that document.

State of

County of

On before me,

(Insert name and title of the officer)

personally appeared

who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed

to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their

authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity

upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under

the laws of the State of California that the foregoing paragraph is true and correct

WITNESS my hand and official seal.

(SEAL)

(SIGNATURE OF NOTARY PUBLIC)