Name of deceased:______________________________________________________________________
       (first)                (middle)                     (last)

Date of death:_________________________________________________________________________
       (mo)                   (date)                       (year)

Approximate year if exact year is unknown:_____________________________________________
                                      (years to be searched)

Place of death:________________________________________________________________________
              (city/township/village)                         (county)

Name of Requester:_____________________________________________________________________
(Please Print)
Address of Requester:__________________________________________________________________

                     __________________________________________________________________


Signature_____________________________________  Number of Certified Copies desired_____

FEE SCHEDULE   1st Certified Copy ...$18.00   Additional Copies ...$5.00
               Non-Certified Copy ...$ 5.00