Ripley County Health Department
Vital Records Division
Death Certificate Application
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PLEASE INCLUDE THE FOLLOWING
ITEMS WITH YOUR REQUEST:
1.
MUST
INCLUDE PHOTOCOPY OF DRIVERS LICENSE
2.
$10.00
FOR A CERTIFIED COPY OR $4.00 (PER NAME SEARCH) FOR A COMPUTER PRINT-OUT
3.
(CASH OR MONEY ORDER ONLY.)
4.
SELF
ADDRESSED STAMPED ENVELOPE
5.
COMPLETED
APPLICATION
IF ANY ITEM FROM THE LIST IS OMETTED
YOUR REQUEST WILL BE RETURNED TO YOU
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Name of Deceased:
_________________________________________________________________________
Date of Death: _____________________________________________________________________________
Place of Death: _____________________________________________________________________________
Your Relationship to Deceased: ________________________________________________________________
Signature of person filling out this application:
______________________________________________
Address & Daytime Telephone of person filling out this application:
__________________________________
__________________________________________________________________________________________
Records start in 1882
All information above must be accurate.
You must be able to prove relationship.
Our records do not list the parent's names.
You may also get information by writing
to: Ripley County Historical Society
P.O. Box 525
Phone Number: 812-689-3031