Informant, or have a vested interest. â 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