Monroe County Health Department - Monroe County Government

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Informant, or have a vested interest. ○ Must provide proof of relationship. Some examples are birth certificate, obitu
Monroe County Health Department Monroe County, Indiana ● CERTIFIED COPY $16.00

Health Department 119 W. 7th Street (812) 349 -2543

Futures Family Planning Clinic

Public Health Clinic

119 W. 7th Street (812) 349 -7343

333 E. Miller Drive (812) 353 -3244

APPLICATION FOR DEATH RECORD

● GENEALOGICAL COPY $15.00

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY ● Death records may be issued to the following: Parents, Spouse, Adult Children, Grandparents, Siblings, Aunts/Uncles, Niece/Nephew, Funeral Home/Director, Cousins, Informant, or have a vested interest. ● Must provide proof of relationship. Some examples are birth certificate, obituary, or marriage license. ● At least one form of identification is required. If applying through the mail, A PHOTOCOPY OF THE APPLICANTS DRIVER'S LICENSE IS REQUIRED ALONG WITH A PHOTOCOPY OF THE CHECK WRITER'S I.D. ● Mail Orders: Payment by Check or Money Order.

●● IF CERTIFICATE IS TO BE MAILED, PLEASE ENCLOSE A SELF-ADDRESSED, STAMPED ENVELOPE ●● NAME OF DECEDENT: ** DEATH MUST HAVE BEEN IN MONROE COUNTY **

DATE OF DEATH:

PURPOSE FOR WHICH RECORD IS TO BE USED: YOUR RELATIONSHIP TO PERSON WHOSE DEATH RECORD IS REQUESTED: DOCUMENTATION FOR PROOF OF RELATIONSHIP/VESTED INTEREST: YOUR SIGNATURE:

DATE:

YOUR MAILING ADDRESS: CITY & STATE: FOR OFFICE USE ONLY

CERT#

ZIP: #Copies _______

Cash ____

Reciept #

Check# _______________

____DL#

PHONE: Credit ____

Debit ____

Total $ ___________

Exp: