Washington State Department of Health - Vital Records Forms · Washington state form

DOH 422-186 Authorized Representative Form – Spanish

Use this form to authorize another person to request an eligible Washington birth, death, or fetal death certificate on behalf of a qualified applicant.

What this form is

The Spanish-language DOH 422-186 Authorized Representative Form lets a qualified applicant authorize someone to request a birth, death, or fetal death certificate. The applicant and the proposed representative each sign before a notarial officer, who completes the corresponding certification. The representative must submit the completed form with the application for the record identified on it within 60 days of certification. The form may be used once.

Who needs it

A qualified applicant who wants another person to request an eligible birth, death, or fetal death certificate on their behalf needs this form.

Why it needs a notary

Both the qualified applicant and authorized representative must sign before a notarial officer. A commissioned online notary can notarize each signature.

How to submit it

The authorized representative submits the completed form with the completed application for the identified record within 60 days of certification. Record applications may be made online, by phone, by mail, or in person.