ABC COUNTY HEALTH DEPARTMENT

Application For Death Record

Applicant Name

Street Address

City

State

Zip

Phone

Email Address

Name of Deceased

Birthdate of Deceased (mm-dd-yyyy)

Date of Death (mm-dd-yyyy)

Father Name of Deceased

Mother Name of Deceased

Place of Death

Relationship to Deceased

# of Copies Requested

Fee for Certified Copies - $15.00 each

Amount

Comments

Applicant Signature

Date of Application (mm-dd-yyyy)

Attach Document (PDF, JPG, PNG, GIF, TIFF Only)
You may add up to 5 files one at a time; on submit they are combined into a single PDF.

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ABC County Health Department