Application for a death certificate

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: