Request for Death Certificate by WorkSession

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Request for Death Certificate

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									                                 Request for Death Certificate

Date: _____________



____________________________

____________________________

____________________________

[insert address of vital statistics office]



Name of deceased: ____________________________

Date of death: ____________________________

Social Security number: ____________________________

Place of birth: ____________________________

Place of death: ____________________________



Please send me ________ certified copies of the death certificate of the above-named person. I
have enclosed a check in the amount of $_____ and a stamped, self-addressed envelope. The
reason for my request is to administer the affairs of the deceased's estate.

Thank you for your assistance.



Signature: ___________________________________________

Printed or typed name: ____________________________

Relationship to deceased: ____________________________

Address:        ____________________________

____________________________
Home phone: ________________   Work phone: ____________________

								
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