NAME OF DECEASED____________________________________________

PLACE OF DEATH_______________________________________________

DATE OF DEATH________________________________________________

SIGNATURE OF PERSON REQUESTING CERTIFICATE
__________________________________________

TOTAL NUMBER OF CERTIFICATES REQUESTED($7.00 per)____________

CERTIFIED(with stamp-no charge) (YES) (NO)

Directions for use:
(1) When mailing request, please enclose a self-addressed, stamped envelope.
(2) Check or Money Order made to Madison County Health Department.
(3) Mail to--Madison County Health Department, 206 East 9th Street, Anderson, IN 46016