APPLICATION FOR DEATH RECORD
**16-37-1-8 Indiana Vital Statistics law requires a Health Officer may only issue a certified copy
if he/she is satisfied by the applicant's direct interest in the record.
Name of Applicant
Address
City
State
Zip Code
Phone #
Email
Relationship to Record Requested
**proof of relationship may be required for issuance
Please call 765-747-7721 ex. 752, 750 or 765 for questions on validating documents.
Name of Decedent
Date of death
Did Decedent's death occur in Delaware County? Circle one: YES or NO
If NO, in what county did the death occur?
Will the record be used for Genealogical purpose? YES or NO
Purpose for which record is to be used
Certified Death Certificates are $20 for each copy, payable by money order or cashier's check.
Number of Copies requested
x $20
Uncertified Genealogical Copies are $10
Number of Copies requested
x $10
Total Amount Remitted: $
The following items MUST be submitted with your request to avoid delays
Photo copy of *CURRENT PICTURE ID
* PAYMENT: money order or cashier's check (no personal checks)
* SELF ADDRESSED STAMPED ENVELOPE.
* ANY SUPPORTING DOCUMENTATION OF PROOF OF RELATIONSHIP
Signature
Date
Office use only:
ID#
Searched By
Date
