Application for Copy of Death Record

PLEASE COMPLETE FORM AND ENCLOSE FEE

FEE: $10.00 per copy or No Record Certification. Please do not send cash or stamps.

PLEASE PRINT OR TYPE

• Name of Deceased (First, Middle, Last)
• Date of Death or Period to be Covered by Search
• Name of Father of Deceased (First, Middle, Last)
• Social Security Number of Deceased
• Maiden Name of Mother of Deceased (First, Middle, Last)
• Date of Birth of Deceased (Month, Day, Year)
• Age at Death
• Place of Death (Name of Hospital or Street Address, Village, Town or City, County)
• Purpose of Which Record is Required?

• What was your relationship to the deceased?
• In what capacity are you acting?
• If attorney, name and relationship of your client to deceased
• Signature of Applicant
• Date
• Address of Applicant

COMPLETE FOR DEATHS OCCURRING AS OF JANUARY 1, 1988

• Number of copies requested with confidential cause of death
• Number of copies requested without confidential cause of death

PLEASE PRINT NAME AND ADDRESS WHERE RECORD SHOULD BE SENT

• Name
• Address
• City
• State
• Zip Code

DOH-294A (6/2000) - Page 1 of 1