Print or type the information in ink 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the NAME OF DECEDENT AS SHOWN ON THE DEATH CERTIFICATE. Ensure accuracy as this is a critical field.
3. Next, fill in the DECEDENT’S DATE OF DEATH and DECEDENT’S PLACE OF DEATH (CITY AND/OR COUNTY).
4. In the MEDICAL SECTION, provide INCORRECT INFORMATION AS IT APPEARS ON THE DEATH CERTIFICATE followed by the CORRECT INFORMATION. Make sure to print or type clearly.
5. Complete the REQUESTOR section by filling out your relationship to the decedent and providing your contact information. Remember to sign where indicated.
6. Finally, review all entries for accuracy before submitting your request. Ensure you have included any required documentation and payment details.

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