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Application For Death Certificate and/or
Birth Resulting in Stillbirth Certificate
Note: The only death records on file are for
those which occurred and were reported in Noble County;
and there are none prior to 1882.
Please complete all items below:
Full Name of Deceased/Stillbirth
_______________________________________________________________
Date of Death/Stillbirth
_______________________________________________________________________
Purpose For Which Record Is Requested:
__________________________________________________________
Name/Signature of Person Applying:
______________________________________________________________
Address:
_________________________________________________________________Telephone__________
Relationship to
Deceased________________________________________________________________________
`````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````
Do Not Write Below This Line
Sex__________ Color __________ Single/Married/Divorced__________ Age______
Cause of Death/Stillbirth
________________________________________________________________________
___________________________________________________________________________________________
Place of Burial: ___________________________________________________________Date
of Burial_________
Funeral Director
__________________________________________________________License
No.:___________
Coroner or M.D.
_______________________________________________________________________________
Fees: $10.00 per Certificate.
Genealogy research:
$10.00 nonreturnable per name for search and information.
Terms of
Payment: Money order or cash. Checks are not accepted. Enclose
self-addressed stamped envelope.
Noble County, Indiana Department of Health
Suite C, Vital Records, 2090 N State Road 9
Albion, Indiana 46701
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