INSTRUCTIONS

COPIES REQUESTED

FEE IS $21.00 FOR THE FIRST COPY AND $4.00 FOR EACH ADDITIONAL COPY OF THE SAME RECORD REQUESTED BY THE APPLICANT  IN A SINGLE REQUEST AND MUST BE SUBMITTED WITH THIS APPLICATION ALONG WITH A COPY OF YOUR DRIVERS LICENSE.

PLEASE TYPE OR PRINT LEGIBLE

CERTICATE OF DEATH

HOW MANY? ___________

AMOUNT ENCLOSED $__________

PLEASE INCLUDE I.D. INFORMATION

D.L. NUMBER_______________________ STATE ISSUED__________________________

INFORMATION ABOUT DECEASED PERSON

1. FULL NAME OF 

     DECEASED       

FIRST

MIDDLE

LAST

2. DATE OF DEATH

MONTH

DAY     /   YEAR

3. AGE

4. DATE OF BIRTH

MONTH

DAY    /    YEAR

STATE

5. MOTHERS NAME

OF DECEASED

FIRST

MIDDLE

MAIDEN NAME

6. FATHERS NAME

OF DECEASED

FIRST

MIDDLE

LAST

PERSON REQUESTING CERTIFICATION OF DEATH

7. PURPOSE  IN OBTAINING COPY?

8. RELATIONSHIP TO PERSON NAMED IN ITEM 1 ABOVE (PARENT, CHILD, SIBLING, ATTORNEY, FUNERAL HOME, ETC.)

9. PRINTED NAME OF APPLICANT

10. ADDRESS OF APPLICANT                      STREET ADDRESS

CITY                                                                                       STATE                                                     ZIP

11. SIGNATURE OF APPLICANT                                                                   12. DATE SIGNED

WARNING: The penalty for knowingly making a false statement in this form can be 2

10 years in prison and a fine up to $5,000. (Article 4477c, Revised Civil Statutes of Texas)