Washington Authorized Representative Form (DOH 422-186)
Official state formOther requestsForm DOH 422-186Free downloadLast verified November 10, 2026
A qualified applicant uses this notarized form to let another person request a Washington birth, death or fetal death certificate on their behalf. The representative submits it with a certificate application to the Washington State Department of Health within 60 days.
Who can use this form
- A qualified applicant for a birth, death or fetal death certificate, who fills out all the fields
- The person named as the representative, who also signs
- Both sign in the presence of a notary. Two different notaries can be used, on one complete form
- The form is for one-time use only
What to send with it
- One complete form with both notarized signatures
- A completed application for the certificate identified on the form, submitted within 60 days of notarization
- Documents proving the representative's identity
- The applicable certificate fees
Where to send it
- Mail to
- See the form for where to file it.
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- July 2025
- Source
- Official government page