Morgan County Health Department

180 S. Main St., Ste. 252

Martinsville, IN 46151

(765) 342-6621

APPLICATION FOR SEARCH AND CERTIFIED COPY OF DEATH

Please complete all items below:

Fee: $12.00 for each certified. Date__________________________

Full Name of Deceased__________________________________________________________

Date of Death_________________________________________________________________

Place of Death_________________________________________________________________

Your relationship to person whose death record is requested:__________________________

Signature of Applicant___________________________________________________________

Applicant’s Address_____________________________________________________________

Phone Number________________________

Please provide 2 various pieces of identification. Send Copies of ID ONLY.

(At least one piece of ID must display current address).

Suggestions of ID are:

Driver's License

State ID

Social Security Card

Work, Military or School ID

Passport

(Any ID with your signature on it)