|
Noble County Health Department
2090 N State Road 9, Suite C
Albion, Indiana 46701
Telephone (260) 636-2191
Fax (260) 636-2192
Clinic Fax: (260) 636-3753
Application For Death Record
Please indicate which type of record or document you would
prefer:
___Certified Death
Certificate - $12
fee
_____Genealogy document $10 fee
Non-certified All searches are non-refundable
Terms of Payment: Money order or Cash only. Checks are not accepted.
Please provide the following information regarding the record you are seeking:
Name of
Deceased
____________________________________________________________________________
Date of Death _________________________Number of
Copies________________________________________
Place of Death
(City/State)______________________________________________________________________
Purpose For Which Record Is Requested:
__________________________________________________________
Your relationship to
deceased____________________________________________________________________
______________________________
_____________________________________________ _______________
Printed name of
Requestor
Signature of
Requestor
Date
Address:
_________________________________________________________________Phone______________
Street
City
State
Zip
IC 16-37-1-8 Indiana Vital Statistics laws
clearly require that a health officer may only issue a certified copy if he/she
is satisfied that the applicant has a direct interest in the record.
....................................................................................................................................................................................................................................................
For Office Use Only
Receipt Number___________________Volume
number________________
Verifier_________________Date Returned__________________________
|