CITY
OF
Request
for Certified Copy of Death Record
$10.00
First Copy - $3.00 each additional copy
(make checks payable to City of Allen Park)
Number
of Copies Requested __________
NAME
OF DECEASED (Print)
_________________________________
First
Middle
Last
DATE
OF DEATH (Month) __________ (Day) _______ (Year) _________
NAME OF HOSPITAL OR ADDRESS WHERE DEATH OCCURED:
____________________________________________
City
__________________ County
________________ State _____
SIGNATURE
OF REQUESTER __________________________________
RELATIONSHIP
TO DECEASED _________________ DATE _________
ADDRESS
______________________________