PUTNAM COUNTY HEALTH DEPARTMENT
VITAL RECORDS
209 W. Liberty St., Room 13
GREENCASTLE, IN 46135
(765) 653-5210
Identification Is Required according to IC 16-37-1-7.
Please submit copies of
two pieces of identification, one should be driver's license or other
picture/signature id and the other can be a copy of the Social Security card.
Complete all items below as required pursuant to IC 16-37-1-7.
Application for Search and/or Certified Copy of Death Record
Please Complete All Items Below
Name of Deceased:_______________________________________________________________
Date of Death:____________________________________________________________________
Place of Death:
City__________________________________ County:___________________
Full Name of
Father:_______________________________________________________________
Full Name of
Mother:______________________________________________________________
Purpose for which the
record is requested: ____________________________________________
Your relationship to the
deceased:___________________________________________________
Form of identification:
_____________________________________________________________
Signature of
Applicant:_____________________________________________________________
Mailing
address:__________________________________________________________________
City and
State:_______________________________________________Zip:_________________
Phone
Number____________________________________________________
Enclose $11.00 check
or money order for each Certified Death Certificate
For Office Use Only
Date Received: ________________________Total
Certificates:____________________________
Volume:
___________________________________Page:___________________________________
Certificate
number:_____________________________File date:___________________________
Clerk:___________________________________________________________________________
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