Wisconsin Report of Court Order to Amend Cause of Death on a Death Record (F-05054)
Official state formCorrections and amendmentsForm F-05054Free downloadLast verified November 14, 2026
Reports a court order that amends, or impounds and replaces, the cause of death on a Wisconsin death record. The clerk of court completes and seals Parts III and IV, then the form goes to the Wisconsin State Vital Records Office with the fee.
Who can use this form
- A person who petitions the circuit court in the county where the death occurred.
- Parts III and IV must be completed by the court before the form is returned to the office.
- The form covers amending the cause of death, or impounding the record and creating a new one.
What to send with it
- The completed form, signed and sealed by the clerk of court.
- A check or money order payable to State of Wis. Vital Records.
- A current certified copy of the death record, which the form says to gather with the evidence for the court.
- Fees listed on the form: $10 to amend the existing record or $20 to create a new death record, then $20 for the first certificate copy and $3 for each additional copy.
Where to send it
- Mail to
- State Vital Records Office ATTN: PSSU PO Box 309 Madison, WI 53701-0309
- State fee
- $10 to amend the existing death record or $20 to create a new death record; first certificate copy $20; each additional copy $3. All as printed on the form.
- Typical processing
- Not provided
- Form revision
- 10/2026
- Source
- Official government page