AFFIDAVIT TO OBTAIN CERTIFIED

COPIES OF DEATH CERTIFICATES

Fee: $10.00 per copy

BY PROVIDING EXACT INFORMATION

NAME: ____________________________________________________________

EXACT NAME AS IT HAS BEEN RECORDED ON THE DEATH RECORD (FIRST, MIDDLE, LAST)

PLACE OF DEATH: __________________________________________________________

EXACT PLACE WHERE THE DEATH EVENT TOOK PLACE (CITY)

DATE: ____________________________________________________________

EXACT DATE THE DEATH EVENT OCCURRED (MONTH, DAY, YEAR)

MAIDEN NAME OF MOTHER: _________________________________________________

MAIDEN NAME OF THE DECEASED SUBJECT’S MOTHER

NAME OF FATHER: ___________________________________________________

NAME OF THE FATHER OF THE DECEASED SUBJECT (IF RECORDED)

NUMBER OF COPIES: _________

PURPOSE FOR WHICH CERTIFICATE IS NEEDED:

____________________________________________________________________________________

YOUR NAME:________________________________________________________________________

PLEASE PRINT

YOUR ADDRESS: ____________________________________________________________________

____________________________________________________________________

CITY STATE ZIP CODE

YOUR TELEPONE NUMBER: (________)_________________

AREA CODE

YOUR RELATIONSHIP TO ABOVE NAMED: _______________________________________________

YOUR SIGNATURE:___________________________________________________________________

DATE

FOR OFFICE USE ONLY:

IDENTIFICATION PROVIDED ________________________________________________________

(1 REQUIRED IF PHOTO 2 REQUIRED IF NO PHOTO) _______________________________ _____

RECEIPT NUMBER: ___________________

CHECK OR CASH: ___________________

CERTIFICATE NUMBER(S) _____________________________________________________

PERSON PREPARING CERTIFIED COPY: _________________________________________