Application for a death certificate DCC Logo

Please print application form and complete.
Please read notes before completing
1. Applicant
Name of applicant: Mr/Mrs/Miss/Ms
(State name in full)
Full postal address:
Post Code: Telephone No:
2.
Please state your relationship to the person to whom the certificate relates:  
3.
It would help us if you would state the purpose for which the certificate is required:  
4. Details of death certificate required
Surname of deceased Date of death
   
Forename(s) Place of death (full address or name of hospital)
   
 
Occupation Date of birth or age at death
   
Home address If a married woman please give name and surname of husband
 
 
 
5. Requirements
I require  (number) standard death certificate(s)
6. Remittance enclosed
I enclose a cheque/postal order made payable to Durham County Council, in sterling drawn on a British Bank Sorting Code, for £
7.
Signature: Date:
FOR REGISTER OFFICE USE ONLY
Register No. - Entry No. - District
 
Certificate No.
Date of issue: